Neonatal respiratory distress — diagnostic approach — structured clinical encounter

Station brief (candidate)

You are the neonatal registrar. A 29-week gestation infant is admitted to the neonatal unit with grunting, subcostal recession and a rising oxygen requirement on CPAP 5 cm within the first hour of life. The mother received one dose of antenatal steroids. The team asks you to establish the diagnosis and the management plan. You have 12 minutes with the team and 5 minutes for examiner discussion. [1]

Information available on request

• Gestation 29 weeks, birthweight 1180 g, vaginal delivery, incomplete antenatal steroid course, no meconium, maternal GBS status unknown, membranes ruptured 14 hours. [1]
• CPAP started in the delivery suite; FiO₂ now 0.40; respiratory rate 72, grunting, moderate recession; heart rate 150, pre-ductal saturation 92%. [5]
• Chest X-ray: symmetric reticulogranular (ground-glass) pattern with air bronchograms and low lung volumes. [1]

Tasks

1. Give the diagnosis and justify it from the risk profile, clinical findings and chest X-ray. [1]
2. Outline the stepwise respiratory management, naming the surfactant decision threshold, the preparation and a less invasive administration technique. [1] [3]
3. State which investigation you would perform to evaluate for sepsis and the empiric antibiotic plan. [5] [6]
4. Describe how your management would change if the infant suddenly deteriorated with asymmetrical breath sounds and a shift of the cardiac impulse. [5]

Marking anchors

Must-hit

• Diagnoses RDS on the basis of prematurity, the rising FiO₂ on CPAP, and the classic ground-glass chest X-ray with air bronchograms and low volumes. [1]
• Continues CPAP; gives animal-derived surfactant since FiO₂ exceeds 0.30, by a less invasive technique (LISA/MIST or INSURE), citing the European Consensus Guidelines and SUPPORT trial evidence for CPAP-first. [1] [3] [4]
• Performs a septic screen (blood culture, CRP, FBC) and starts empiric benzylpenicillin plus gentamicin given the prolonged rupture of membranes and unknown GBS status. [5] [6]

Merit

• Names a specific natural surfactant (poractant or beractant) at 100–200 mg/kg intratracheally, and explains that less invasive administration reduces mechanical ventilation and bronchopulmonary dysplasia. [2] [4]
• Sets oxygen targets appropriate to gestation and avoids hyperoxia, recognising retinopathy of prematurity risk. [5]
• Discusses thermoregulation, glucose monitoring, and deferred cord clamping at birth for this gestation as part of anticipatory care. [6]

Fail

• Increases FiO₂ to 0.50 and observes without surfactant when the threshold is exceeded. [3]
• Withholds empiric antibiotics despite prolonged rupture of membranes and unknown GBS status. [5]
• Delays needle decompression of a suspected tension pneumothorax to await a chest X-ray in a deteriorating infant. [5]