Case Analysis on Aspiration Syndrome (MAS)

In Partial Fulfillment of the Requirements in

RT 124- CLINICAL EDUCATION I

PEDIATRIC INTENSIVE CARE UNIT

Submitted to:
PROF. LLOYD L. DEOCADES, RTRP
Clinical Instructor

Submitted by:
ARIANNE KAYE F. ALAVE
Group 6

Date Submitted:
August 06, 2021
 CONTENTS

Cover Page
Contents

I. Definition
II. Assessment
III. Clinical Findings/Symptoms
IV. Risk Factors
V. Pathophysiology
VI. Diagnosis
VII. Management & Treatment

References
Definition

Meconium aspiration syndrome is characterized by difficulty breathing (respiratory

distress) in a baby who has aspirated a dark green, sterile fecal substance known as
meconium into the lungs before or shortly after birth. Aspirated meconium may obstruct
the newborn's airways and cause lungs to collapse after birth. (Balests, 2021).
Meconium is the first stool of an infant, composed of materials ingested during the
period of gestation. Meconium is normally stored in the infant's intestines until after
birth, but sometimes often in response to fetal distress and hypoxia it is expelled into the
amniotic fluid prior to birth, or during labor. If the baby then inhales the meconium, MAS
may occur.

Assessment
Chief Complaint: Respiratory distress with marked tachypnea and cyanosis, nasal
flaring and grunting.

Maternal and Pregnancy History: A 36 year old primagravida mother (G P-0-0-)
had no proper prenatal care and a heavy smoker. During her pregnancy she
experienced gestational hypertension.

Labor and Delivery: The mother has prolonged labor of her child. She delivered her child via
assisted vaginal delivery using forceps at 42 weeks.

Gestational Age Assessment

The baby weighed about 4235 grams. There is a decrease in vernix of the newborn,
and it is stained with a yellowish color, and the Skin and cord are also stained with a
yellowish color with many cracks and wrinkles. Some of it is peeling. Long finger nails
are also inspected. The lanugo is mostly bald. Ear recoil is instant, and the pinna is
formed and firm. The breast has a full areola with a 5-10mm diameter bud
Past Health History
No Past History Indicated

Present Health History

After the completion of delivery, the newborn is seen with cyanosis, audible
grunting and retractions.

General Survey
The neonate is seen with respiratory distress with marked tachypnea and
cyanosis. Expiratory granting and nasal flaring is also evident. The chest appears barrel
shape. The first  minute Apgar of the newborn scored 5 ( Activity-  arms and legs
flexed, Pulse- 2 ,Grimace-0 flaccid, Appearance- 0 Blue pale, Respiration-2 Vigorous
cry). The 5 minute Apgar score of the newborn is 7 ( Activity- 1 arms and legs flexed,
Pulse- 2 Over 100 Bpm ,Grimace-1 some flexion of extremities, Appearance- - 0 Blue
pale, Extremities blue, Respiration-2 Vigorous cry). The initial vital signs of the newborn
show the respiratory rate of 73cpm, Systolic Blood pressure of 73 mmHg and Diastolic
blood pressure of 45, Pulse rate of 155bpm, SpO2 85%, Temperature of 36.4℃.

APGAR SCORING SYSTEM (first  minute)

Activity  (arms and legs flexed)

Pulse 2 (Over 100 Bpm)

Grimace 0 (Flaccid)

Appearance 0 (Blue, pale)

Respiration 2 (Vigorous Cry)

 5 - Moderately Depressed

APGAR SCORING SYSTEM (first 5 minute)

Activity  (arms and legs flexed)

Pulse 2 (Over 100 Bpm)

Grimace  (some reflexion of extremities)

Appearance 0 (Blue, pale)

Respiration 2 (Vigorous Cry)

6 - Moderately Depressed

Vital signs
RR of 73cpm, Systolic Blood pressure of 73 mmHg and Diastolic blood pressure
of 45, Pulse rate of 155bpm, SpO2 85%, Temperature of 36.4℃.

Cephalocaudal Assessment
Head
 Upon inspection head has no lesions and deformities present, Hair color is black
and fine. Anterior and Posterior fontanelles is firm but soft upon palpation.
Mouth
 Blue discoloration can be seen around the lips and mouth
Ears
 Position of the ears is lower than the head
 The ear quickly reopen after being folded
Neck
 Clavicles are intact, tonic neck reflex is present, neck-righting reflex is present,
short and thick
Chest and Lungs
 The chest appears barrel shape with increase AP diameter, Auscultation of the
chest reveals rales as well as areas of significantly diminished aeration
Abdomen
 Dome-shaped abdomen, Abdominal respirations
 Yellowish pigmentation of the skin and umbilical cord

Reflex

Root Reflex Present When the corner of the baby’s mouth was
stroked, the baby turned his head and
opened his mouth to follow the direction of
the stroke.

Suck Reflex Not Present Newborn baby

Moro Reflex Present Arms and legs extended out when the baby
cried.

Tonic Neck Reflex Not Present The baby is still a newborn.

Grasp Reflex Present When the baby’s palm was stroked, the baby
closed his fingers in a grasp.

Babinski Reflex Present When the sole of the newborn’s foot was
 stroked, the big toe moved upward and the
other toes fanned out.

Step Reflex Not Present The baby is still a newborn.

Clinical Findings/Symptoms

Signs and Symptoms

1. Meconium stained skin, nails and umbilical cord
2. Signs of respiratory distress develop usually within the 1st hour of birth:
A. Tachypnea,
B. Intercostal retractions,
C. Coarse bronchial sounds,
D. Expiratory grunting, and/or
E. Cyanosis.
3. Chest may be overinflated/ barrel shaped

Differential Diagnosis
 Respiratory Distress Syndrome
 Transient Tachypnea of Newborn
 Congenital heart disease
 Bacterial Pneumonia

Risk Factors
Risk factors include all which induce fetal distress and hypoxia:
  Preeclampsia
 Head or cord compression
 Oligohydramnios,
 Maternal infections
 Postdate pregnancy/Post maturity
 Maternal heavy cigarette smoking

Pathophysiology

Physiological meconium passage Fetal Distress ( Cord or fetal

(Particularlly if Postdates) compression, hypoxia, prolonged labor)

Meconium stained amniotic fluid

Postpartum Aspiration Intrauterine Gasping

Meconium Aspiration

Cytokine induced
Airway obstruction Surfactant
pneumonitis
Dysfunction

Pulmonary Air Trapping

Hypoxia
Atelectasis Decrease lung
Acidosis
compliance
V/Q mismatch

PPHN
Diagnosis
- Diagnosis of meconium aspiration syndrome is suspected when a neonate
shows respiratory distress in the setting of meconium-containing amniotic
fluid.

Chest Radiographs

-Diagnosis is confirmed by chest x-ray showing hyperinflation with variable

areas of atelectasis and flattening of the diaphragm. Bilateral patchy areas
increased density

Management & Treatment

 Oxygen Therapy
Administration of 02 is critically important and in many neonates is all that will be
needed for respiratory therapy. The Target saturation range is 91% - 95%. The
Target Pa02 is 60-90 mmHg.
 Mechanical Ventilator
Indicated for excessive carbon dioxide retention (Pac02 >60mmHg) or for
persistent Hypoxemia (Pa02 <50 mmHg)

Ventilator Settings:
 PIP: 25-30 CM H20
 PEEP: 0-3 CM H20
 Rate: 40-60/ min
 I:E ratio: :3

Positive-pressure ventilation should not be administered to a nonvigorous infant until a

thorough suctioning of the upper airways has been completed, because any particulate
meconium remaining in the upper airways likely will be forced into the lower airways in
response to positive-pressure ventilation.

 Surfactant Therapy
Surfactant within the lung may be hindered by the presence of meconium,
surfactant replacement therapy can be considered as a treatment for MAS.

American Academy of Pediatrics NRP guidelines:

 If the baby is not vigorous : - direct suction immediately after delivery - suction for
no longer than 5 sec, If no meconium retrieved, do not repeat intubation and
suction - If meconium is retrieved and no bradycardia present, re-intubate and
suction.
 If baby is vigorous : - Clear secretions and meconium from the mouth and nose
with a bulb syringe or a large bore suction catheter

 Antibiotics
The use of broad-spectrum of antibiotics can eliminate possible infections.
References:
Balests, A. L. (2021, July). MSD Manual Consumer Version. Retrieved August 6, 2021, from
msdmanuals: https://www.msdmanuals.com/home/children-s-health-issues/lung-and-
breathing-problems-in-newborns/meconium-aspiration-syndrome

Des Jardins, T., Burton, G. (2016). Clinical Manifestations and Assessment of Respiratory
Disease (7th ed.). Elsevier Inc.
Walsh, B. K. (2015). Neonatal and Pediatric Respiratory Care Pageburst E-book on Kno
(Fourth, pp. 424, 429). W B Saunders Company