Respiratory difficulty with neonatal expiratory moan

Specialty: Pediatrics.

• Respiratory distress of the newborn
• neonatal respiratory moan

Why it occurs

• Transient tachypnea of the newborn or wet lung (delay in the reabsorption of fetal alveolar fluid, more common in cesarean deliveries without prior labor)
• Hyaline membrane disease or surfactant deficiency (typical of premature newborns due to immaturity of type II pneumocytes)
• Meconium aspiration syndrome (small airway obstruction and chemical inflammation due to intrauterine meconium, common in term or post-term neonates with fetal distress)
• Early neonatal sepsis or bacterial pneumonia (mainly caused by Streptococcus agalactiae or Escherichia coli with inflammation and alveolar edema)
• Persistent neonatal pulmonary hypertension (failure in the circulatory transition with persistence of high pulmonary vascular resistance)
• Ductus-dependent congenital heart disease (severe aortic coarctation, transposition of the great arteries, left ventricular hypoplasia)

Initial workup

Continuous pulse oximetry and emergency cardiorespiratory monitoring. Anteroposterior portable chest x-ray (to differentiate radiological patterns: diffuse reticulonodular infiltrate in ground glass with air bronchogram in hyaline membrane; fluid in fissures and hyperinflation in transient tachypnea; thick cottony patches in meconium aspiration). Arterial or capillary blood gases (to evaluate hypoxia, hypercapnia and respiratory or mixed acidosis). Complete blood count, CRP, procalcitonin and paired blood cultures (to rule out infectious origin). Urgent echocardiogram if congenital heart disease or persistent pulmonary hypertension is suspected.

Standard management

• Natural pulmonary surfactant of porcine or bovine origin — like Curosurf; administered intratracheally using minimally invasive techniques such as MIST/LISA or conventional intubation in newborns with proven surfactant deficiency and high FiO2 requirements
• Ampicillin plus Gentamicin — first-line neonatal empiric antibiotic regimen for sepsis/pneumonia; ampicillin at a dose of 100 mg/kg/day IV divided every 12 hours; gentamicin at doses of 4 to 5 mg/kg IV every 24-36 hours, monitoring serum levels in premature infants
• Alprostadil or Prostaglandin E1 (continuous intravenous infusion at doses of 0.01 to 0.1 mcg/kg/min to keep the ductus arteriosus open in suspected ductus-dependent heart disease).