CASE PRESENTATION

MARIE ANJANETTE B. PAASA

Post-Graduate Intern
 OBJECTIVES
• To discuss a case of a newborn patient presenting with
dyspnea

• To discuss the etiology, risk factors, clinical presentation,

pathophysiology, management and prognosis of patient
with TTN
HISTORY AND
PHYSICAL EXAMINATION
 IDENTIFYING DATA

o Newborn
o male
👶 o
o
Term
Filipino
PATIENT MR o Roman Catholic
o San Dionisio, Paranaque City

Admitted at NICU on August 17, 2019

CHIEF COMPLAINT

dyspnea
 HISTORY OF PRESENT ILLNESS

✓ Patient: born to a 29-year old

G3P2(2001) mother

✓ Maternal History:
(+) PNCU – 7x at PGH
(+) received 1 dose of TT
(+) Supplemented (FeSO4 and MVT)
(+) Normal UTZ and CAS
(-) vices
(-) maternal illnesses
 HISTORY OF PRESENT ILLNESS
✓ Patient: born to a 29-year old
G32(2001) mother
✓ Maternal History:
(+) PNCU – 7x at PGH
(+) received 1 dose of TT
(+) Supplemented (FeSO4 and MVT)
(+) Normal UTZ and CAS
(+) Received 4 doses of Dexa
(-) vices
(-) maternal illnesses
✓ At 36 wk AOG, mother had
contractions, given 4 doses of
dexamethasone
✓ At 37 wk, mother went into labor
hence scheduled for STAT CS
✓ Delivery: LSCS, assisted by physician
at PGH, noted with difficulty on fetal
extraction
 HISTORY OF PRESENT ILLNESS

✓✓Patient: born
Delivered to a 29-year old
term-looking, 12th min of life: 17th min of life:
G32(2001) mother stained,
non-meconium (+) retractions (+) retractions
spontaneous HR 110s HR 130s
✓ Maternal History:
respiration, good cry RR 80s RR 80s
(+) PNCU – 7xfair
and tone, at activity
PGH T 35. 2 T 36. 2 NICU
(+)
✓ received
EINC done1 dose of TT ✓ Suctioning done ✓ O2 @ 2LPM
(+)
✓ Supplemented
Apgar Score of(FeSO4
8,9 and MVT)✓ Thermoregulation
(+) Normal UTZ and CAS
(+) Received 4 doses of 1 Dexa
5
(-) vices A 1 1
(-) maternal illnesses
P 2 2
G 2 2
A 1 2
R 2 2
 FAMILY HISTORY

(+) Mother had history of IUGR (preeclampsia)

(-) congenital anomalies
(-) metabolic disorders
 PERSONAL-SOCIAL HISTORY
▪ Second child
▪ Father: 30-yo sales agent
▪ Mother: 29-yo housewife
 REVIEW OF SYSTEMS
General: (+) good suck (+) good cry (-) febrile
Skin: (+) rashes
Eyes: (-) eye discharges
Ears, Nose, Throat: (+) alar flaring (-) nasal discharges (-) mouth breathing
Cardiorespiratory: (-) cough and cyanosis
Gastrointestinal: (-) BM (-) vomiting
Genitourinary: (-) urine output
Neuromuscular: (-) abnormal postures or spasms
 PHYSICAL EXAMINATION

GENERAL SURVEY Awake, alert, tachypneic,

With the following vital signs of:

T: 36.5 BP: 70/28, 60/32, 62/35, 60/36 mmHg

HR: 120s RR: 70s
O2 sat: 97%

Length: 47 cm Weight: 2600 grams

HC: 34cm CC: 31cm AC: 26cm
Z-SCORE

Z-score: 0
normal
Z-SCORE

Z-score: 0
normal
Z-SCORE

Z-score: 0
normal
 PHYSICAL EXAMINATION

SKIN Warm to touch, good turgor

(+) rashes over chest and neck

HEENT Normocephalic, (-) caput succedaneum

Patent and soft fontanelles
Anicteric sclerae, pink palpebral conjunctivae
(+) alar flaring
 PHYSICAL EXAMINATION

Neck Supple, trachea at midline

C&L Equal chest expansion;

(+) subcostal retractions
Clear breath sounds

Back No abnormal curvatures or sacral dimple

 PHYSICAL EXAMINATION

Heart Distinct heart sounds, normal rate

Regular rhythym, no murmur

Abdomen Globular, normoactive bowel sounds,

No organomegaly
 PHYSICAL EXAMINATION

Genitalia Grossly male genitalia

Descended testes, good rugae

Extremities Symmetrical
Good, equal pulses
CRT <2 sec
 Summary of the Case

A case of a newborn, born to a 29 yo G3P2(2001) mother, fullterm,

BW= 2600 grams, AGA, delivered via repeat LSCS with noted difficulty
on fetal extraction due to fetal position, AS 8, 9.

At12th min of life, patient noted to have subcostal retractions,

thermoregulation and suction done, however still with SC retractions;
hence hooked to O2 via nasal cannula @ 2LPM.
 Salient Features
HISTORY PHYSICAL EXAMINATION
✓Term ✓no cyanosis
✓No maternal comorbidities ✓O2 sat=97%
✓Cesarean delivery ✓No BP derangement
✓Non-meconium stained ✓Tachypneic @ 70s
amniotic fluid ✓Subcostal retractions
✓AS 8,9 ✓Clear breath sounds
✓No murmurs
APPROACH TO DIAGNOSIS
TACHYPNEA

Pulmonary Non-pulmonary causes

APPROACH TO DIAGNOSIS
TACHYPNEA

Pulmonary Non-pulmonary causes

 TACHYPNEA

Pulmonary Non-pulmonary causes

Non-infectious Infectious Cardiac Metabolic

 TACHYPNEA

Pulmonary Non-pulmonary causes

Non-infectious Infectious Cardiac Metabolic

CHD
▪ No murmur
▪ No cyanosis
▪ No Hx of CHD
▪ No genetic abn
 TACHYPNEA

Pulmonary Non-pulmonary causes

Non-infectious Infectious Cardiac Metabolic

CHD Hypoglycemia
▪ No murmur IEMs
▪ No cyanosis
▪ No Hx of CHD ▪ No history of IEM
▪ No genetic abn ▪ Rare
▪ No maternal RF
▪ Noted >6hr of life
 TACHYPNEA

Pulmonary Non-pulmonary causes

Non-infectious Infectious Cardiac Metabolic

CHD Hypoglycemia
▪ No murmur IEMs
▪ No cyanosis
▪ No Hx of CHD ▪ No history of IEM
▪ No genetic abn ▪ Rare
▪ No maternal RF
▪ Noted >6hr of life
 TACHYPNEA

Pulmonary

Non-infectious Infectious
 TACHYPNEA

Pulmonary

Non-infectious Infectious

Structural Meconium Respiratory Transient Tachypnea

• Pulmonary Hypoplasia
• Diaphragmatic Hernia Aspiration Syndrome Distress Syndrome of the Newborn
• TEF
× No noted
abnormalities
on CAS
 TACHYPNEA

Pulmonary

Non-infectious Infectious

Meconium Respiratory Transient Tachypnea

Aspiration Syndrome Distress Syndrome of the Newborn
• Intermediate (onset)
• Term/post term

× Not meconium stained

 TACHYPNEA

Pulmonary

Non-infectious Infectious

Respiratory Transient Tachypnea

Distress Syndrome of the Newborn
• Intermediate (onset)
• Male sex

× Preterm
× Not surfactant deficient
 TACHYPNEA

Pulmonary

Non-infectious Infectious

Transient Tachypnea
of the Newborn
• Occur anytime of
gestation
• Immediate (onset)
• CS delivery
• Male sex

× Cannot totally rule out

 TACHYPNEA

Pulmonary

Non-infectious Infectious

Transient Tachypnea
of the Newborn
• Occur anytime of
gestation
• Immediate (onset)
• CS delivery
• Male sex

× Cannot totally rule out

 TACHYPNEA

Pulmonary

Non-infectious Infectious

Transient Tachypnea
of the Newborn
• Occur anytime of
gestation
• Immediate (onset)
• CS delivery
• Male sex

× Cannot totally rule out

 TACHYPNEA

Pulmonary

Non-infectious Infectious

Transient Tachypnea
of the Newborn Neonatal Pneumonia
• Occur anytime of
• Occur anytime of
gestation
gestation
• Possible aspiration of
• Immediate (onset)
contents
• CS delivery
• Male sex
× Cannot totally rule out
× Cannot totally rule out
 Impression
➢ Fullterm, 37 weeks by Pediatric Aging, 2600 grams,
appropriate for gestational age, cephalic presentation,
delivered via LSCS
Live baby boy, Apgar Score 8, 9

➢ Transient Tachypnea of the Newborn

➢ To consider Neonatal Pneumonia
 PLAN OF MANAGEMENT
OBJECTIVES
1. Reduce work of breathing • O2 supplementation Consider antibiotics
• Thermoregulate

2. Confirm diagnosis • Imaging: BBG

• ABG

3. Rule out Neonatal Pneumonia CBC, CRP, Blood CS

and Sepsis
CASE DISCUSSION
TRANSIENT TACHYPNEA OF THE NEWBORN
TRANSIENT TACHYPNEA OF THE NEWBORN
▪ Benign self-limited respiratory distress syndrome of term and
late preterm infants related to delayed clearance of lung liquid

▪ Appears after birth and resolves within 3-5 days

▪ Most common perinatal respiratory disorder

Pathophysiology → Delayed resorption of liquid from the lungs

Liquid in lungs inhibits gas exchanges

increased work of breathing

tachypnea
Factors
1. Inactivated/immature amiloride-
sensitive sodium channels

DURING LABOR → surge of catecholamines

are released and the lung switches from
active chloride secretion to active sodium
absorption
Factors
2. Uterine contractions
increases abdominal pressure, elevates the diaphragm, and
increases transpulmonary pressure, thereby forcing liquid out
via the nose and mouth

3. Pulmonary immaturity Surfactant deficiency leads to an increased surface tension and

lowers the compliance of the lung
Other Risk Factors
• Cesarean delivery
• Male gender
• Prematurity/late preterm
• Macrosomia
• Multiple gestation
• Prolonged labor
• Birth asphyxia
• Breech delivery
• Precipitous labor
• Low apgar
CLINICAL MANIFESTATIONS
▪ Near term, term, large and premature

▪ Shortly after delivery:

✓ tachypnea (>60/min)
✓ Grunting
✓ Nasal flaring
✓ Retractions
CLINICAL MANIFESTATIONS

Tachypnea can be differentiated:

1. Transitional delay subsides within 6 hours
2. Transient tachypnea of the newborn (TTN) <72 hours;
typically resolves 12-24 hours
3. Prolonged tachypnea of the newborn >72 hours
DIAGNOSIS

LABORATORY
1. ABG : mild hypoxemia; hypocarbia

2. Rule out other causes:

- CBC
- Plasma endothelin-1 levels
- Interleukin-6
- ANP
DIAGNOSIS

IMAGING
1. CXR:
hyperinflation, perihilar streaking,
prominent pulmonary vascular markings
Intralobar fluid accumulation

2. Lung ultrasonography:
shows difference in lung echogenicty
between upper and lower lung areas
DIAGNOSIS
✓ Rule out other causes of tachypnea:
T: TTN
R: respiratory infections
A: Aspiration syndromes (meconium, blood, amniotic)
C: congenital malformations
H: hyaline membrane disease
E: edema
A: air leaks, acidosis
MANAGEMENT
✓ General management is supportive

▪ Oxygenation
▪ Maintain neutral thermal environment
▪ Antibiotics
▪ OGT Feeding
▪ Diuretics are not recommended
PROGNOSIS
✓ Self limited (lasts 2-5 days)
✓ TTN is associated with the development of wheezing
syndromes in early childhood
✓ Complications:
• prolonged tachypnea
• Respiratory failure
• Air leaks (pneumothorax)
• Pulmonary hypertension
THANK YOU
GENERAL
MEDICAL