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  • TTN is a self-limited disorder characterized by tachypnea and other signs of mild respiratory distress such as retractions and cyanosis.
  • Occurs secondary to a delayed clearance of fetal lung liquid, which leads to airway compression, bronchiolar collapse, and air trapping.

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Risk Factors

Clinical Manifestation

Differential Diagnosis



  • Prematurity
  • Precipitous delivery
  • C-section delivery without labor
  • Presentation within 6 h of birth
  • Tachypnea, typically 60–120 breaths/min + mild-to-moderate respiratory distress
  • Physical examination: good air entry ± crackles
  • Symptoms tend to last 12–72 h
  • Pneumonia
  • Sepsis
  • RDS (may complicate TTN, especially if infant is premature)
  • Cyanotic heart disease
  • Meconium aspiration
  • Persistent pulmonary hypertension
  • ABG: may see mild hypoxemia with mild respiratory acidosis
  • CXR: prominent perihilar streaking and mild-to-moderate cardiomegaly
  • May also see hyperinflation, pleural effusions, and widened fissures
  • Supportive with supplemental O2, as TTN is a self-limited disease
  • May need CPAP for lung recruitment (may increase the risk of air leak)
  • May offer PO feeding when RR <70 breaths/min and weaned to room air
  • Diuretics have not been shown to improve symptoms or shorten course and are contraindicated
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Risk Factors

Clinical Manifestation



  • Prematurity
  • Male sex
  • Caucasian race
  • Maternal diabetes
  • Perinatal asphyxia
  • C-section without labor
  • Thoracic malformations
  • Genetic disorders of surfactant production


  • Tachypnea, grunting, and retractions
  • O2 requirement tends to increase over the first 48 h if not treated

Laboratory/radiographic findings:

  • CXR: diffuse, fine granular densities that develop during the first few hours of life
  • Hypotension (treat as appropriate)
  • A PDA can lead to poor recovery from RDS, and closure should be considered if patient is 3–4 d old with hemodynamic compromise or continued RDS with poor weaning from mechanical ventilation

Surfactant therapy:

  • Many centers start CPAP and do not give “prophylactic” surfactant therapy.
  • Many formulations are available. Check with your institution to determine the appropriate dosage/interval/number of doses.
  • Consider prophylactic surfactant therapy as soon as clinically feasible for infants <27 wk gestation who require intubation.
  • For all other infants, early rescue surfactant (within 1–2 h after birth) is indicated for worsening respiratory distress on exam or increasing Fio2 requirement above 30%–40%.
  • Lack of antenatal corticosteroid therapy in infants 24–34 wk gestation
  • ABG: hypoxia, hypercarbia, mild metabolic acidosis, ± elevated lactate

Monitoring/supportive therapy:

  • ABG: should be checked within 30–60 min of surfactant therapy or with changes in ventilator settings
  • Temperature: neutral thermal environment should be maintained
  • Antibiotics: RDS is difficult to distinguish from pneumonia and sepsis; consider appropriate cultures and initiate broad-spectrum antibiotics (ie, ampicillin and gentamicin) for 48 h
  • Ensure appropriate ETT position and equal lung inflation prior to giving surfactant.
  • Dosage: 4 mL/kg (Survanta dosing) per ETT q4–6h for up to four doses.
  • Pulmonary hemorrhage can be seen after surfactant therapy; this is thought to result from rapid change in lung compliance.


  • O2 saturations alarms should be 85%–97% if ≥1250 g and 85%–93% if <1250 g ...

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