Neonatal expiratory moan with nasal flaring and rib retraction

Specialty: Pediatrics.

• Respiratory difficulty in the newborn
• neonatal respiratory distress

Why it occurs

• Transient tachypnea of the newborn or wet lung syndrome (delay in reabsorption of alveolar fluid by apical epithelial sodium channels, common in full-term or late preterm newborns born by cesarean section without prior labor)
• Hyaline membrane disease or respiratory distress syndrome type I (deficiency of endogenous pulmonary surfactant that increases alveolar surface tension causing collapse and progressive atelectasis, typical of premature newborns)
• Meconium aspiration syndrome or MAS (physical obstruction of the small airway, chemical pneumonitis and surfactant inactivation by intrauterine meconium in term or post-term neonates with a history of fetal distress)
• Early onset neonatal sepsis or connatal pneumonia (bacterial infection by Streptococcus agalactiae or Escherichia coli with diffuse alveolar inflammation and edema)
• Persistent pulmonary hypertension of the newborn (persistence of high pulmonary vascular resistance after birth with right-left shunt).

Initial workup

Continuous pulse oximetry and emergency cardiorespiratory monitoring. Portable anteroposterior chest x-ray (to differentiate patterns: air bronchogram and diffuse "ground glass" reticulonodular infiltrate in hyaline membrane; hyperinflation with fluid in fissures in transient tachypnea; bilateral thick cottony patches and irregular infiltrates in meconium aspiration). Arterial or capillary blood gases (to quantify hypoxia, hypercapnia and respiratory or mixed acidosis). Blood analysis with complete blood count, PCR, procalcitonin and paired blood cultures (to rule out infectious origin). Urgent echocardiogram in case of suspicion of congenital heart disease or pulmonary hypertension.

Standard management

• Natural pulmonary surfactant of porcine or bovine origin — like Curosurf; dose of 100 to 200 mg/kg administered intratracheally using minimally invasive techniques such as MIST/LISA or by conventional endotracheal tube in premature neonates with proven hyaline membrane and high oxygen requirements
• Ampicillin plus Gentamicin — empirical broad-spectrum neonatal antibiotic regimen indicated as an emergency if sepsis/pneumonia is suspected; 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 with monitoring of serum levels in premature infants
• Alprostadil or Prostaglandin E1 (continuous intravenous infusion at doses of 0.01 to 0.1 mcg/kg/minute to maintain the patency of the ductus arteriosus in suspected ductus-dependent heart disease).