Clinical Judgment: Pulmonary
The big five
Respiratory distress syndrome (RDS): surfactant deficiency in preterm infants, onset within hours, grunting, retractions, ground-glass film with air bronchograms; antenatal steroids plus early CPAP or surfactant are the mainstays. Transient tachypnea of the newborn (TTN): term or near-term, often after cesarean birth, tachypnea with fluid in the fissures that resolves in 24–72 hours with supportive care. Meconium aspiration syndrome: term or post-term, meconium-stained fluid, patchy infiltrates, air leak, and pulmonary hypertension; tracheal suctioning is reserved for the non-vigorous infant. Pneumothorax: sudden deterioration, asymmetric chest, shift in transillumination; needle decompression precedes the radiograph. Bronchopulmonary dysplasia: supplemental oxygen or respiratory support at 36 weeks' postmenstrual age, driven by volutrauma, oxygen, infection, and inflammation.
Ventilation concepts
Avoid both atelectrauma and volutrauma: use the lowest oxygen and pressures that meet targets, accept permissive hypercapnia when pH allows, and remember that hyperoxia contributes to retinopathy of prematurity and BPD. Apnea of prematurity - a pause over 20 seconds, or shorter with bradycardia or desaturation - is treated with caffeine and CPAP.
Traps
Calling any tachypnea RDS; forgetting that TTN worsening after 72 hours means pneumonia, sepsis, or heart disease; missing a pneumothorax in a ventilated infant who suddenly desaturates; and reflexively suctioning every meconium-stained delivery.
Worked example
A term infant born by scheduled cesarean is tachypneic at 80 breaths/min at 2 hours, needs 30% oxygen, and has prominent fissures on chest radiograph. That is TTN: provide CPAP or oxygen as needed, support feeding, and reassess by 72 hours. Persistent distress prompts a sepsis evaluation and echocardiogram.