Curriculum vitae

Nama : dr Lily Rundjan, SpA(K)

Tempat/tanggal lahir : Surabaya, 3 Juni 1969

Riwayat Pendidikan Formal

Fakultas Kedokteran Universitas Indonesia, Jakarta, 1986-1992
PPDS-1 Departemen IKA FKUI-RSCM, Jakarta, 2000-2004
Konsultan Divisi Perinatologi, 2011
Riwayat Pekerjaan
Staf Pengajar Divisi Perinatologi FKUI-RSCM, Maret 2008 sekarang
Satgas Farmasi IDAI, 2008 - sekarang
Riwayat Pelatihan tambahan
Neonatal Training di the Royal Womens Hospital Melbourne dan the
Royal Children Hospital Melbourne, 2006 - 2008
Lily Rundjan
Neonatology Division, Child Health Department
Faculty of Medicine University of Indonesia
Cipto Mangunkusumo Hospital
 Background

Respiratory distress is a common respiratory problem

faced by GPs and pediatricians.

Understanding pathophysiology of respiratory distress

will help in the management and improve the outcome.

Challenging ventilation management: should

reach optimal ventilation in a timely manner for a better
outcome.
Causes of respiratory distress

Pulmonary.
Cardiac Congenital Heart Disease,
Myocardial dysfunction.
CNS asphyxia
Metabolic hypoglycemia, acidosis,
hypothermia
 Causes of/

Medical - Meconium aspiration

syndrome, transient tachypnea
of newborn hyaline membrane
disease, Pneumonia, Asphyxia,
Acidosis.
Surgical - Pneumothorax, Tracheo
oesophageal fistula,
Diaphragmatic hernia.
Approach to respiratory distress

History
Onset of distress
Gestational age
Antenatal steroids
Predisposing factors PROM, fever
Asphyxia
Aspiration
 Respiratory distress

2 symptoms found:

Nasal Chest
Tachypnea
flaring retraction

Cyanotic
Grunting
in room air
Asessment of severity of respiratory distress
in neonates
Downe Score
0 1 2

RR < 60 x/min 60-80 > 80 x/min

Retraction - Mild Severe

Cyanosis - Cyanosis relieved Cyanosis on O2

by 02

Air entry Good air entry Mild decrease in No air entry

air entry

Grunting No grunting Audible by Audible with ear

stethosope
Ventilation management based on
respiratory distress severity

Downe Score

<4 4-5 6

Mild Respi. Moderate Respi. Severe Respi.

Ditress Distress Distress

Non invasive Non invasive BGA + considering

ventilation ventilation intubation
Respiratory distress
 PATOPHYSIOLOGY OF RDS
SURFACTANT DEFICIENCY

Alveolar collapse at end-expiration

Right to
FRC Lung compliance * left
shunt
Tidal volume **
Patients effort
to increase
pressure
Impaired oxygenation

Inefficient effort to
Glottis closure during promote the flow of
Cyanosis
expiration inspiratory gas
to prevent alv.collapse

Grunting * Intercostal ** Nasal

** Tachypnoe flaring
retraction
Fetal to Neonatal Transition

Replacement of alveolar fluid with air

Bagaimana bayi memperoleh
oksigen setelah lahir?
 Pulmonary Blood Flow

Before birth After birth

 Oxygen Saturation Target

Extrauterine (after birth):

transition time to achieve SaO2
untill 90%
Intrauterine:
SaO2 60% Preterm babies 6,5 min (4,9-9,8
min)
At Term babies 4,7 min (3,3-6,4
min)
 Oxygen Saturation Target
Time after birth Oxygen saturation target for
newborn baby during
resuscitation (%)
1 minute 60-70
2 minute 65-85
3 minute 70-90
4 minute 75-90
5 minute 80-90
10 minute 85-90

The International Liaison Committee on Resuscitation

(ILCOR) recommended to use the pulse oxymetri to observe
the Oxygen saturation in DR.
Resuscitation Algorithm (IDAI 2014)
Optimal ventilation in Delivery Room

Assessment

Inadequate spontaneous
breathing/ gasping
Spontaneous breathing + RD
Apneu
HR<100x/min

Early CPAP in DR PPV

X
PPV
 Optimal ventilation in DR (preterm babies)
Observe
improvement/ Retraction :
worsening of PEEP may
retraction / increase up to
Preterm CPAP 8 cm H2O
infants, Downes
with score
spontaneous PEEP 7
breathing, cmH2O
RD

CPAP failure
Assessment criteria * (PEEP
Preterm 8 cmH2O, Considering
infants, PPV with FiO2 >40%) + surfactant
inadequate PEEP no history of administration
breathing/ antenatal
apneu steroid
*CPAP failure criteria: BGA (pH<7,25,
PaCO2 > 60 mmHg, PO2 < 40 mmHg)
Respiratory distress management in
delivery room
When the baby has mild-moderate
respiratory distress start early CPAP
ASAP and OPTIMAL
Do not give free flow oxygen or nasal
cannulae
Do not withhold oxygen therapy in DR

When the baby has severe respiratory

distress PPV and intubate
 Free Flow Oxygen
Bayi yang dapat bernapas tetapi mengalami sianosis sentral
free flow oxygen

Resusitasi Selang oksigen di Balon Mengembang Sendiri

mengunakan Neopuff antara telapak Laerdal (dekat, tidak rapat)
(1 cm di atas wajah) tangan seperti Tidak diremas dengan oksigen
96% (termasuk PEEP) bentuk sungkup 100% dan kecepatan aliran 5
93% (tidak termasuk (1 cm di atas wajah) L/min (1 cm di atas wajah )
PEEP) 90% 39-56% 22
Ventilation device in delivery
room
Any chosen device must provide PEEP/CPAP to facilitate the
development of FRC immediately after birth, improve oxygenation
and reduce atelectrauma
Self-inflating bag with PEEP valve
Flow-inflating bag/ Jackson-Rees system in limited facilities
T-piece resuscitator/ Neopuff
 Self inflating bag
Advantages Disadvantages
Does not need gas Cannot deliver CPAP
source Does not have PEEP for
PPV attached PEEP
valve provides
inconsistent PEEP
Self-inflating bag with PEEP valve

Advantage: no need for source of gas

Disadvantage: cannot be used as CPAP,
Without PEEP

With PEEP
 Flow inflating bag
Advantages Disadvantages
Can give CPAP Cannot work if there is
no flow / gas source
Cannot have mask leak
the bag will not inflate
Variable PEEP for PPV
 Flow-inflating bag
(Jackson-Rees)

With mask With single nasal prong

Advantage : can be used as CPAP

Disadvantage: cannot be used to give positive pressure ventilation, need source of gas,
inconsistent PEEP delivered
 T-piece resuscitator
Advantages Disadvantages
Can give CPAP Depends on gas source
Provides consistent and if limited T-piece
predetermined PIP and resuscitator cannot deliver
PEEP pressure
Can deliver sustained Pay attention to mask leak
inflation predetermined PIP/PEEP
are not reached
Need training to operate
Early NCPAP
 CPAP in transport
Intra hospital
Use cut down ET tube
connected to Neopuff in the DR
and ventilator on transport cot
during transfer
Only side effect seen is
dislodgement of nasal tube into
upper GI tract (RWH)
Ideal facility in Delivery Room

T-piece resuscitator and

blender

Infant warmer
 in limited facilities

alternative: mixing oxygen

No blender
and compressed air
Tabel Konsentrasi Oksigen
untuk Campuran Udara dan Oksigen
Udara Bertekanan (liter/menit)
%
kons. O2
1 2 3 4 5 6 7 8 9 10

1 41% 37% 34% 32% 31% 30% 29% 28%

2 61% 53% 47% 44% 41% 38% 37% 35% 34%

3 80% 68% 61% 55% 51% 47% 45% 43% 41% 39%
4 84% 74% 66% 61% 56% 52% 50% 47% 45% 44%
Oksigen (liter/menit

5 86% 77% 70% 65% 61% 57% 54% 51% 49% 47%
6 88% 80% 74% 68% 64% 61% 57% 54% 53% 51%
7 90% 82% 76% 71% 67% 64% 61% 58% 56% 54%
8 91% 84% 78% 74% 70% 66% 63% 61% 58% 56%
9 92% 86% 80% 76% 72% 68% 65% 63% 61% 58%
10 93% 87% 82% 77% 74% 70% 67% 65% 63% 61%
35
Respiratory distress Management in
Neonatal Unit
Nasal cannulae
Non Low flow

invasive High flow

CPAP
Ventilation Bubble CPAP and CPAP with ventilator
NIPPV

Conventional
Invasive Target VTE 4-6 mL/kg

Ventilation* Target MV 0,24-0,36

HFOV

*Invasive ventilation >>> risk of VILI &

BPDconsidering Vt and FiO2 level
Case:

How much FiO2 that is given for an

ELBW infant (BW = 1 kg) with 100%
oxygen concentration through nasal
cannulae of 1 L/min?
STOP ROP FIO2 CONVERSION TABLE
 Good chest rise
Mucous obstruction, position, leakage, and
inadequate inflation pressure?
Optimal
ventilation in
clinical Heart rate
perspectives
Decreased work of breathing

Improved colour / O2 saturation

exclude pain/ stress

CONFIRMED WITH:

Chest X-Ray
well-expanded (observe 8th-9th posterior rib spaces)

Blood gas analysis

PaO2 > 40 mmHg, PaCO2 < 60 mmHg, pH >7,25, BE < (-) 12
Transportation of respiratory distress babies
Jackson Rees for transport
 Conclusion
Knowledge of optimal ventilation for newborn in
newborn infants is very important for GP to
prevent the progresivity of RD and improve the
outcome,
 Do Not
Administer O2 via nasal Use head box (O2 4
cannulae (low PEEP), with L/min FiO2 delivered:
FiO2 >40% toxic level 100%)

Considering the optimal level of PIP and

PEEP to administer oxygen therapy