Neonatal respiratory distress — diagnostic approach — branching viva

Station opening

Examiner: "Define neonatal respiratory distress and list the clinical signs you would look for." [5]

Strong candidate (must-hit)

• Defines it as laboured breathing after birth with tachypnoea above 60 per minute, recession, grunting, nasal flaring and cyanosis, with hypoxaemia or hypercapnia; explains grunting as physiological positive end-expiratory pressure to splint alveoli open. [5]

Weak candidate

• "It's when the baby is breathing fast." [5]

Branch A — The preterm infant

Examiner: "A 28-week infant has grunting and an FiO₂ of 0.35 on CPAP 5 cm. What is your diagnosis and your next step?" [1]

Strong

• Diagnoses RDS by virtue of prematurity and CPAP failure at FiO₂ above the 0.30 threshold; plans exogenous (animal-derived) surfactant by a less invasive technique (LISA/INSURE) while continuing CPAP, citing the 2022 European Consensus Guidelines and the SUPPORT trial for the CPAP-first approach. [1] [3]

Weak

• "Increase the oxygen and wait." [3]

Branch B — The meconium trap

Examiner: "A term infant born through meconium-stained liquor is apnoeic and limp. A colleague wants to intubate and suction the trachea first. What do you say?" [5]

Strong

• States that routine intubation and tracheal suctioning is NOT recommended for the non-vigorous meconium infant per AHA 2020 and ERC 2021; the priority is to ventilate, beginning positive-pressure ventilation for this apnoeic, bradycardic infant. [5] [6]

Weak

• "Yes, suction first — that's the whole point for meconium." [5]

Branch C — The silent killer

Examiner: "A term infant has respiratory distress with a clear chest X-ray and saturations that will not rise above 85% in high-flow oxygen. Pre-ductal is 96%, post-ductal 83%. What is happening and what is your immediate action?" [5]

Strong

• Recognises differential cyanosis (a greater than 10% pre/post-ductal gradient) indicating a right-to-left ductal shunt; diagnoses a duct-dependent congenital heart lesion; starts an intravenous prostaglandin E1 infusion at 0.01–0.05 microgram/kg/min and arranges urgent echocardiography and cardiac retrieval. [5] [6]

Weak

• "It must be RDS — give surfactant." [5]

Branch D — Cord management in the preterm

Examiner: "Another preterm infant at 26 weeks is about to deliver. The team suggests cord milking to speed the transfusion. Comment." [7]

Strong

• States cord milking is contraindicated below 28 weeks; cites the Katheria 2019 JAMA trial showing an excess of severe intraventricular haemorrhage that stopped the trial early; recommends deferred cord clamping for at least 30 seconds with active warming instead. [7]

Weak

• "Milking is a reasonable way to get the transfusion done quickly." [7]

Close

Examiner: "Summarise your diagnostic approach to neonatal respiratory distress in one sentence." [1]

Strong

• "I gestate the infant first — preterm means RDS and CPAP with surfactant at an FiO₂ above 0.30; term means a chest X-ray, gas and septic screen to split TTN, MAS and sepsis, and any term infant whose saturations will not climb in oxygen gets a pre/post-ductal check, an echocardiogram and prostaglandin E1 if the duct is critical." [1] [5]