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Problem solving in clinical practice
Galvanised by a respiratory distress diagnosis
  1. M E Abdel-Latif1,2,
  2. J Oei1,2,
  3. M Ward1,2,
  4. E J Wills3,
  5. V Tobias2,4,
  6. K Lui1,2
  1. 1
    Department of Newborn Care, Royal Hospital for Women, Randwick, NSW 2031, Australia
  2. 2
    School of Women’s and Children’s Health, University of New South Wales, Kensington, NSW 2032, Australia
  3. 3
    Electron Microscope Unit, Concord Repatriation General Hospital, Concord, NSW 2139, Australia
  4. 4
    Department of Pathology, Sydney Children’s Hospital, Randwick, NSW 2031, Australia
  1. Dr Kei Lui, Department of Newborn Care, Royal Hospital for Women, Barker Street, Locked Bag 2000, Randwick, 2031 NSW, Australia; Kei.Lui{at}SESIAHS.HEALTH.NSW.GOV.AU

https://doi.org/10.1136/adc.2007.126227

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    The third pregnancy of a 38-year old Caucasian G3P2 woman had been unremarkable apart from pregnancy-induced cholestasis and group B streptococcus (GBS) detected on a routine 35-week high vaginal swab and for which intrapartum penicillin was administered. Following induction of labour at 38 weeks’ gestation for worsening cholestasis, the woman proceeded to a normal vaginal delivery of a live male infant. There was no maternal pyrexia and the liquor was clear. The parents were non-consanguineous and neither the parents nor the other siblings had a history of pulmonary disease.

    The baby was born with Apgar scores of 8 and 9 at 1 and 5 min, respectively. He developed respiratory distress almost immediately, with an audible grunt, flaring of the alae nasi and tachypnoea. Oxyhaemoglobin saturation (SpO2) was 82% when breathing room air so the infant was placed in a head box (HB) with fractional inspired oxygen (FiO2) of 40% to maintain SpO2 >95%. A chest x ray (CXR) showed a coarse reticular-granular pattern appearance, fluid in the right horizontal fissure and low lung volume. Blood cultures were collected and empirical antibiotics (amoxycillin and gentamicin) were started. Capillary blood gas analysis at this stage showed: pH 7.26, pCO2 61, pO2 32, BE 0.7. Over the next 3 h, oxygen requirement decreased to FiO2 32%, but the infant remained tachypnoeic.

    The NICU registrar thought the respiratory distress was probably due to transient tachypnoea of the newborn (TTN) or congenital pneumonia.

    COMMENT 1: CAUSES OF RESPIRATORY DISTRESS IN A TERM NEWBORN BABY

    • The differential diagnosis of respiratory distress in full-term newborn infants includes a wide range of disorders that may directly or indirectly involve the lungs (table 1). It is useful to differentiate the common causes of respiratory distress according to gestational age. Hyaline membrane disease (HMD), for example, is more common among preterm infants, while meconium aspiration …

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    Footnotes

    • Funding: None.

    • Competing interests: None.

    • Ethics approval: Approval for the study was obtained from the governing human research ethics committees of the involved Area Health Service in New South Wales, Australia.

    • Patient consent: This scenario is based on a real case. Parental informed consent was obtained for publication of the person’s details, x rays and lung biopsy results in this report.