Chapter 42. Pulmonology

• 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

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

Clinical:

• 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.

Oxygen:

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