Neonatal and Pediatric Respiratory Care

In depth

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Lung development and surfactant

Type II cells make surfactant from about 24 weeks, but enough to keep alveoli open at end-expiration usually arrives only near 35 weeks. Without it, surface tension collapses alveoli at each breath, compliance falls and the baby grunts (exhaling against a closed glottis to hold volume), flares and retracts. Antenatal steroids speed maturation, while maternal diabetes delays it, which is why phosphatidylglycerol is the more reliable marker in diabetic pregnancies. A lecithin/sphingomyelin ratio under 2:1 without phosphatidylglycerol predicts RDS.

Europe 2025 starts CPAP from birth in any baby at risk who does not need intubation, gives surfactant early once FiO₂ reaches 0.30 on CPAP or ultrasound shows RDS, prefers thin-catheter delivery (LISA) for spontaneously breathing babies, and allows a second or third dose for persistent need. Doses are poractant alfa 200 mg/kg (2.5 mL/kg) first, beractant 100 mg/kg (4 mL/kg) and calfactant 105 mg/kg (3 mL/kg). Watch for transient desaturation or bradycardia during dosing, reflux up the tube, and pulmonary hemorrhage or pneumothorax after.

The Silverman–Andersen score grades distress from 0 to 10 using chest lag, intercostal retraction, xiphoid retraction, nasal flaring and expiratory grunt (0–2 each); higher is worse. On film, RDS gives low volumes with diffuse ground glass and air bronchograms; transient tachypnea gives fluid in the fissures and normal or high volumes; meconium aspiration gives patchy densities with hyperinflation and air leaks; neonatal pneumonia can look like any of them.

Bronchopulmonary dysplasia and apnea

Jobe and Bancalari (2001) define BPD in babies born under 32 weeks as oxygen for at least 28 days, graded at 36 weeks postmenstrual age: mild if in room air, moderate if under 30% oxygen, severe if 30% or more or on positive pressure. Prevention means less invasive ventilation, volume targeting, caffeine, avoiding hyperoxia and good nutrition; Europe 2025 considers a short low-dose dexamethasone course for babies still ventilated after 1–2 weeks at high risk of death or BPD. About a fifth of babies with evolving BPD develop pulmonary hypertension, for whom higher saturation alarms are reasonable.

Apnea of prematurity (AAP 2016) is a pause of 20 seconds or more, or a shorter pause with bradycardia, cyanosis or pallor, in a baby under 37 weeks, after infection, anemia, temperature instability, hypoglycemia, seizures and drugs have been excluded. Caffeine reduces apnea, shortens ventilation and lowers BPD; CPAP or nasal ventilation splints the upper airway against obstructive and mixed events. Infants going home on oxygen need caregiver training, written targets and escalation steps, RSV prophylaxis and follow-up.

Conventional and oscillatory ventilation

Volume-targeted ventilation is the first choice in RDS (Europe 2025, A1). Start near 5 mL/kg with a PIP ceiling of 25–30 cm H₂O and a backup rate near 30; needs rise toward 6–7 mL/kg with age and evolving BPD. After surfactant, compliance improves so fast that a fixed PIP gives rising volumes, the main cause of post-surfactant pneumothorax. Permissive hypercapnia (about 5–7 kPa, or 38–53 mm Hg) speeds extubation, with caffeine given before it.

Oscillators deliver volumes near the dead space at 480–900 breaths a minute around a constant mean pressure. Oxygenation follows MAP and FiO₂; CO₂ removal (DCO₂) is proportional to frequency × tidal volume², so tidal volume matters most. Raising amplitude enlarges each breath; lowering frequency lengthens each cycle so that a piston moves more gas, which is why a lower Hz lowers PaCO₂ unless volume guarantee holds the volume constant. Optimal inflation is usually 8–9 posterior ribs on the film; more flattens the diaphragm and impedes venous return.

Before oscillating, suction and confirm the tube position, because the circuit should stay closed. Get a gas 15–20 minutes after starting and after changes. Wean FiO₂ first, then MAP in 1–2 cm H₂O steps; babies can go straight to CPAP when MAP is about 8–10 cm H₂O with a stable breathing pattern. High-frequency jet ventilation is an alternative for air leak and pulmonary interstitial emphysema.

Pulmonary hypertension and the oxygenation index

In PPHN, pulmonary pressure stays above systemic after birth and blood shunts right to left across the ductus and foramen ovale. Meconium aspiration, sepsis, asphyxia and diaphragmatic hernia are common causes. The preductal saturation exceeds the postductal; treatment is oxygen, avoiding acidosis and hypothermia, sedation, lung recruitment, surfactant for parenchymal disease, blood pressure support and inhaled NO.

Example: MAP 18 cm H₂O, FiO₂ 1.0 and PaO₂ 45 mm Hg give an OI of 18 × 1.0 × 100 ÷ 45 = 40, the conventional ECMO threshold. INOmax is labeled for babies over 34 weeks at 20 ppm; monitor NO₂ and methemoglobin, keep a backup delivery system, and wean in steps rather than stopping, because abrupt withdrawal causes rebound hypoxemia and pulmonary hypertension. In pediatric ARDS an OI of 16 or more is severe.

Pediatric airway and home care

Croup narrows the subglottis, the narrowest part of a child's airway, so a millimeter of swelling raises resistance sharply. Racemic epinephrine works within 30 minutes but wears off in about 2 hours, so children are watched for 2–4 hours after the last dose; L-epinephrine is equivalent. Heliox lowers turbulent resistance but has weak evidence and limits FiO₂. Cool mist has shown no benefit. A child who looks toxic and fails epinephrine may have bacterial tracheitis.

Bronchiolitis care (AAP 2014) is supportive: nasal suction, oxygen when SpO₂ is under 90%, and fluids; albuterol, epinephrine, steroids, antibiotics and chest physiotherapy are not recommended, and hypertonic saline only for inpatients. In PARIS (2018), high-flow at 2 L/kg/min after standard oxygen failed cut escalation of care. Prongs should fill no more than half of each naris.

Children with tracheostomies go home with two trained caregivers, a portable suction unit, a self-inflating bag, spare tubes in the same size and a size smaller, humidification and, if ventilated, a backup ventilator or battery and a notice to the power company. A suction catheter that will not pass means the tube is blocked: change it at once.

NBRC emphasis and exam pearls

• Neonatal or pediatric content runs through the exam (about 15–18 items).
• Preterm on CPAP with FiO₂ climbing past 0.30: surfactant.
• Chest rise jumps after surfactant: lower PIP and FiO₂.
• SpO₂ 99–100% on supplemental O₂ in a preterm infant: lower FiO₂.
• HFOV with high PaCO₂: raise amplitude (or lower Hz); low PaO₂: raise MAP or FiO₂.
• Cesarean without labor, fluid in the fissures: transient tachypnea.
• Sudden collapse on the ventilator with unequal chest: transilluminate and decompress.
• OI = MAP × FiO₂ × 100 ÷ PaO₂; 40 means ECMO referral.