hdm - report final

8/3/2019 Hdm - Report Final

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A Case Reportby:

PGI Joanna Rose F. Estayo

HYALINE MEMBRANE DISEASEHYALINE MEMBRANE DISEASE

(respiratory distress syndrome)


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Patient Profile

Live, preterm baby boy delivered via stat CS

secondary to twin pregnancy to a 35 year old

G1P0 35 4/7 weeks by LMP, 33 weeks by MT,BW = 2090 grams, AS 9,9, AGA

Date of Birth: 10/04/10

Time of Birth : 2125H


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Anthropometrics

Birth weight = 2090 grams

Birth length = 47 cm

Head Circumference = 33cm

Chest Circumference = 28 cm

Abdominal Circumference = 26 cm


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Birth and Maternal History

35 year old G1P0

(+) regular prenatal check-up

HbsAG and VDRL non-reactive CBC, UA, OGTT normal

No maternal illness during the pregnancy

No fetomaternal complications

Gestation in wks: 35 4/7 weeks by LMP

Manner of Delivery : stat CS


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Physical Examination (on admission)

General Apperance:

vi

gorous Skin: pink

Head: normocephalic, no caput succedaneum

Neck: supple

Eyes/ENT: no discharge, (+) ROR, (+) alar flaring

Lungs: equal chest expansion, clear breathsound,(+) grunting, tachypnea

Heart: no murmurs

Abdomen: globular, soft

Genetalia: grossly male

Anus: patent Extremities: no gross deformties

Reflexes: intact

Trunk/Spine: midline


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Course in the Wards10 mins

after birth

O >(+) alar flaring

(+) grunting(+) tachypneaO2 sat @room air 85% --> O2 @ 1lpm vianasal canula, --> 87% --> O2 @ 2 lpm --> 100%Hgt = 72 mg/dl

P>For CXR: Hyaline Membrane DiseaseDiagnostics: CBC with PC, BCS, ABOFor isoletteHook to pulse oximeterIVF: D10 W 170cc to run @ 7cc/hr

NPOStart antibiotics:

Piptazo 100mg IV q12 hrs (96mkD)Amikacin 30mg IV q 24 hrs (14.6 mkD)

WOF: respiratory distress, cyanosis, O2desaturation


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3 hrs

after birth

8 hrs

after birth

9 hrs

After birth

O> (+) alar flaring, (+) grunting(+) subcostal retraction,(+) tachypnea

(+) desaturation 80s

P> For CPAP, FiO2 40%, PEEP = 6For ABGFor Ambubagging x 15 mins

O> Still with persistence of signs ofrespiratory distress

P> Increase PEEP to 7

For surfactantvi

a ET

tube, thenextubate

S/P Surfactant (4cc/kg) via ET , 8mlO2 sat = 97%


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9.5 hrs

after birth

11 hrs

after birth

18 hrsafter birth

O2 saturation = 83%FiO2 increased to 50%PEEP = 7

O saturation = 94%

Increase PEEP to 9, FiO2 decrease to 40Wean CPAP , slowly tapering FiO2, for O2saturation > 95 %If FiO2 remains >0.30 @ 1400H, give 2nd

dose of surfactant

O> RR= 72, O2 sat = 94-98 %

deep subcostal retractionsgood air entry, clear BS

P> For 2nd dose of surfactant


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19 hrs

after birth

2nd dayof life

S/P surfactantO2 sat = 95%(+) subcostal retractions

Continue weaning CPAP

O> active, good cry(+) subcostal retractionsgood air entry, clear BSRR = 50 70sO2 sat = 93-97%

P> CPAP setting 25% @ 9 cmIVF (TFI : 100cc/kg/day)


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3rd day

of life

4th day

of life

O> active, good cry(+) minimal subcostal retractionsgood air entry, clear BSRR = 50sO2 sat = 95%

P> CPAP setting 21% @ 8 cmIVF (TFI : 110cc/kg/day)

Revise CPAP to FiO2 =21, PEEP = 6,TFR = 6FiO2 =21, CA= 5, O2= 0,TFR = 5

Start oral feeding, if breastmilk is notavailable, start Pre Nan 10cc q3 hrs per OGT

Once tolerated may decrease IVF


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6th day

of life

7th day

of life

8th day

of life

O> good activity, good cry(+) subcostal retractionsgood air entry, clear BS

O2 sat = 96-97%No desaturations

P> Discontinue CPAPIncrease feeds as toleratedContinue antibiotics to complete for

7 days

DC pulse oximeterDC IVFIncrease feeds

DC isoletteIncrease feedsEncourage breast feeding


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alient Features

preterm baby boy (35 4/7 weeks by LMP, 33 weeks byMT)

delivered via stat CS secondary to twin

2nd of twin

BW = 2090 grams, AS 9,9,

No fetomaternal complications

No maternal illness during pregnancy

Alar flaring

Grunting

Tachypnea

Subcostal retractions

Desaturation


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Differential Diagnoses

TransientTachypnea of the Newborn

Neonatal Pneumonia

Hyaline Membrane Disease


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Transient Tachypnea of the Newborn

Reasons for Ruling In Reasons for RulingOut

(+) alar flaring

(+) tachypnea (+) retractions

(+) grunting

CS delivery

Tachypnea not relieved by

O2 support alone Patient still have minimal

retractions on the 6th dayof life


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Neonatal Pneumonia

Reasons for Ruling In Reasons for RulingOut

(+) alar flaring

(+) tachypnea (+) retractions

(+) grunting

No maternal illness /

unremarkable PMHx ofmother

No prolonged rupture ofmembranes

No other s

igns of seps

is /

infection

Blood CS : NEGATIVE

CBC: normal


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Reasons for Ruling InReasons for RulingOut

(+) alar flaring

(+) tachypnea

(+) retractions

(+) grunting

Prematurity

Male sex

CS delivery

Multiple gestation

CXR result: reticulogranularpattern, ground glassappearance, (+) air bronchogram,

flattened diaphragm

Marked improvement aftersurfactant therapy

---------


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Assessment


(Respiratory Distress Syndrome)


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Definition

Clinical diagnosis ofHyaline Membrane Disease iswarranted in a preterm newborn with the ff:

Respiratory difficulty

Tachypnea (>60 cpm) Chest retractions Cyanosis

*** progresses over the first 48-96 of life

CXR: uniform reticulogranular pattern andperipheral air bronchogram


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Incidence

HMD occurs in 44% ofinfants with

birthweight between 501 and 1500 grams

Incidence is inversely proportional to the

gestational age and birthweight


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Pathophysiology

Primary cause : SURFAC

TAN

TDEFICIENCY

SURFACTANT

produced by type II alveolar cells at 28 to 34 wks

Appears in amniotic fluid between 28 and 32 wks Mature levels present after 35 wks reduces surface tension within the alveoli help to maintain alveolar stabilitybypreventing

collapse of alveoliat end expiration

Major constituents of surfactant: dipalmitoylphosphatidylcholine (lecithin) phosphatidylglycerol apoproteins (surfactant proteins SP A,B,C,D) cholesterol


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Overly compliant chest wall

Decreased intrathoracic pressure

Shunting


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Risk Factors

Increased Risk Decreased Risk

Prematurity

Male sex Familial predisposition

Cesarean delivery withoutlabor

Peri

natal asphyxi

a Chorioamnionitis

Multiple gestation

Maternal diabetes

Chronic intrauterine stress

Prolonged rupture ofmembranes

Maternal hypertension

Narcotic/cocaine use

IUGR or SGA Corticosteroids

Thyroid hormone

Tocolytic agents


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Clinical Presentation

History Physical Examination

Preterm (by dates orgestational examination)

Hx of asphyxia in theperinatal period

Px with respiratory difficultyat birth, which becomesprogressively severe

Worsening of atelectasis onthe CXR

Increasing oxygenrequirement

Tachypnea

Grunting Nasal flaring

Retractions of the chest

wall

Cyanosis


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MANAGEMENTOF

HMD


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Diagnostics

Chest Radiography

- uniform reticulogranular pattern (ground-glass

appearance) and peripheral air bronchogram Blood gas sampling

Sepsis work-up (CBC and BCS)

Serum glucose levels Serum electrolytes

Echocardiography


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Prevention

Antenatal corticosteroid

enhances fetal lung maturity Betamethasone - two 12mg doses via IM 24 hours apart

Dexamethasone - increased risk for cystic periventricularleukomalacia

Antenatal ultrasonography and continuous fetalmonitoring

Tocolytic agents

Assessment of fetal lung maturity before delivery lecithin-to-sphingomyelin ratio phosphatidylglycerol


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urfactant Replacement

now considered a standard of care in the

treatment ofintubated infants with HMD.

Surfactant prophylaxis (within 15 mins ofbirth) is recommended to almost all infants


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Respiratory Support


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Other Additional Management

Fluid and Nutritional Support

AntibioticTherapy

- Usually wide spectrum antibiotics are used Sedation

- Might be indicated for infants who fight the

vent

ilator and exhale dur

ing the

insp

iratorycycle of mechanical ventilation


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Prognosis

Survival ofinfants with HMD has improved

greatly during the past years

Prognosis for survival with or without

respiratory or neurologic sequelae is highly

dependent on birthweight and gestational

age .


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References:

Kliegman, R. e. (2007).Nelson's textbook of Pediatrics (18th

ed.). Philadephia: Saunders Elsevier.

Philippine Pediatric Society: Standard Care of the Newborn

Thank you!

hdm - report final

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