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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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Hyaline Membrane Disease
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
Hyaline Membrane Disease
(Respiratory Distress Syndrome)
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Hyaline Membrane Disease
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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!