7.4 Neonatal Upper Airway Anomalies, Aspiration, Pneumonia, Chronic Lung Disease & Respiratory Failure
Key Takeaways
Bilateral choanal atresia causes cyclic cyanosis that improves with crying because newborns are preferential nasal breathers; an oral airway or McGovern nipple maintains the airway until repair.
In Pierre Robin sequence (micrognathia, glossoptosis, often cleft palate), prone or side-lying positioning and a nasopharyngeal airway relieve obstruction, and a laryngeal mask is a rescue device when intubation fails.
Laryngomalacia is the most common cause of inspiratory stridor in infants; it worsens when supine, feeding, or crying and is usually benign, whereas biphasic stridor suggests subglottic or tracheal pathology.
Neonatal pneumonia (often group B streptococcus or gram-negative organisms) can look identical to RDS on radiograph, so empiric ampicillin plus gentamicin is started after cultures in a sick newborn.
Infants with bronchopulmonary dysplasia have fixed airway and vascular disease; transport teams avoid hypoxemia (which worsens pulmonary hypertension), expect bronchospasm and fluid sensitivity, and use their home oxygen and ventilator settings as the baseline.
Neonatal Upper Airway Anomalies, Aspiration, Pneumonia & Chronic Lung Disease
Why the Newborn Airway Is Different
Newborns are preferential nasal breathers for the first months of life. Anything that blocks the nose, pushes the tongue backward, or narrows the larynx or trachea can cause sudden obstruction. Anatomic airway problems also make intubation hard, so the transport team must plan a difficult airway before touching the patient.
Congenital Upper Airway Anomalies
| Anomaly | Presentation | Transport stabilization |
|---|---|---|
| Bilateral choanal atresia | Cyanosis and apnea at rest that improve when the infant cries (mouth breathing); a small suction catheter will not pass through the nares; often part of CHARGE syndrome | Oral airway or McGovern nipple (a nipple with the tip cut off, taped in place); intubate if the airway remains inadequate; ENT repair |
| Pierre Robin sequence | Micrognathia, glossoptosis (tongue falls back), often U-shaped cleft palate; obstruction worse when supine; feeding difficulty | Prone or side-lying positioning; nasopharyngeal airway; prepare for a difficult intubation (video laryngoscopy, laryngeal mask rescue); ENT or airway team |
| Laryngomalacia | Most common cause of inspiratory stridor in infants; floppy supraglottic tissue collapses on inspiration; worse when supine, feeding, or crying; usually benign | Positioning, observation; severe cases (apnea, cyanosis, failure to thrive) need surgical evaluation |
| Vocal cord paralysis | Stridor, weak cry, aspiration; bilateral paralysis can cause severe obstruction and is associated with Chiari II malformation and birth trauma | Airway support; bilateral cases may need intubation or tracheostomy |
| Subglottic stenosis or hemangioma | Biphasic stridor; hemangioma may coexist with cutaneous hemangiomas in a "beard" distribution; stenosis often follows prior intubation | Smaller-than-usual endotracheal tube; avoid repeated attempts; specialist airway team |
| Macroglossia | Beckwith-Wiedemann syndrome (also causes hypoglycemia; Section 10.1), hypothyroidism | Positioning, nasopharyngeal airway |
| Vascular ring or tracheal stenosis | Stridor, wheeze, feeding problems; may worsen with neck flexion | Avoid neck flexion; cardiology and surgical evaluation |
Stridor timing: Inspiratory stridor localizes to the supraglottis or larynx. Biphasic stridor points to the glottis, subglottis, or upper trachea. Expiratory noise (wheeze) suggests intrathoracic airways.
Difficult-airway planning: Before transporting any infant with a known anomaly, confirm the airway plan and backup devices (appropriately sized laryngeal mask, smaller endotracheal tubes, video laryngoscope). Ask whether the infant should be intubated before departure by the most experienced operator available. An airway that is marginal at the referring bedside can fail completely in a moving vehicle.
Aspiration
- Meconium aspiration is covered in Section 7.2.
- Milk or gastric aspiration occurs with swallowing dysfunction, TEF (Section 10.1), gastroesophageal reflux, prematurity, and depressed consciousness.
- Signs: Sudden desaturation, bradycardia, coughing or choking with feeds, and new infiltrates (often in the right upper lobe in supine infants).
- Transport care: Stop feeds, suction the oropharynx, place and vent an orogastric tube, elevate the head of the bed, and support breathing. Antibiotics are reserved for suspected infection rather than given for simple chemical aspiration.
Neonatal Pneumonia
- Early-onset pneumonia (acquired before or during birth) is usually caused by group B streptococcus, E. coli, and other gram-negative organisms. Risk factors include prolonged rupture of membranes, maternal fever or chorioamnionitis, and prematurity.
- Late-onset pneumonia is often hospital-acquired (ventilator-associated): S. aureus, gram-negative organisms, and viruses such as RSV.
- Radiograph: Can mimic RDS (diffuse granular opacities) or TTN, and may be complicated by effusion or PPHN.
- Management: Cultures, then ampicillin plus gentamicin for early-onset disease (Section 6.5). Support oxygenation and ventilation, give surfactant if surfactant inactivation is severe, and watch for septic shock and PPHN.
Chronic Lung Disease: Bronchopulmonary Dysplasia (BPD)
BPD is chronic lung disease of prematurity. It is defined by the need for oxygen or respiratory support over time and assessed at 36 weeks' postmenstrual age. Arrested alveolar and vascular development leaves infants with:
- Heterogeneous lungs: Areas of fibrosis and overinflation, airway malacia, and reactive bronchospasm
- Pulmonary vascular disease: Pulmonary hypertension in a significant minority, made worse by hypoxemia, acidosis, and infection
- Fluid sensitivity: Tendency toward pulmonary edema, and often chronic diuretic therapy
- Chronic respiratory acidosis with metabolic compensation (high bicarbonate). Do not "correct" a chronically elevated PaCO2 to normal.
Transport principles for infants and children with chronic lung disease
- Establish their baseline. Record home oxygen flow, ventilator settings, usual saturations, and the usual blood gas. Many targets are individualized (for example, SpO2 of 92–95% or higher when pulmonary hypertension is present).
- Avoid hypoxemia, including during altitude changes (Section 3.2). It triggers pulmonary vasoconstriction and pulmonary hypertensive crises.
- Treat bronchospasm with bronchodilators, and use longer expiratory times on the ventilator.
- Be careful with fluids. Use judicious boluses and continue home diuretics per medical control.
- Tracheostomy-dependent children are common transport patients. Bring a spare tracheostomy tube of the same size and one size smaller, suction catheters, and a bag with a tracheostomy adapter. If a tracheostomy patient deteriorates, apply DOPE (Section 5.4): suction, check position, and change the tube early if it is obstructed or dislodged. Children with a healed stoma can usually be oxygenated through the stoma or by bag-mask ventilation over the face with the stoma covered if the tube cannot be replaced.
Recognizing Respiratory Failure Before Departure
Signs of impending respiratory failure in neonates include increasing apnea and bradycardia episodes, rising FiO2 needs (for example, above 0.4–0.6 on CPAP), PaCO2 above about 60–65 mmHg with pH below about 7.20–7.25, severe retractions, and worsening grunting. Signs of fatigue are late: a tiring infant may breathe more slowly just before an arrest. Intubation before the transport is usually safer than rescue intubation in transit (Section 6.6).
A term newborn becomes cyanotic and apneic while quiet, but pinks up each time the infant cries. A 6 French suction catheter cannot be passed through either naris. What is the most appropriate immediate intervention?
Place an oral airway or a McGovern nipple to maintain an oral airway
Nasal CPAP with binasal prongs
Deep nasopharyngeal suctioning every 15 minutes
High-flow nasal cannula at 8 L/min
A newborn with micrognathia and a cleft palate has severe obstruction and retractions when supine. What should the transport team do first?
Perform immediate awake direct laryngoscopy with a Miller 0 blade
Place the infant prone or side-lying and insert a nasopharyngeal airway, while preparing difficult-airway backups
Give a paralytic to allow bag-mask ventilation
Start high-dose dexamethasone for airway edema
A 5-month-old former 25-week preterm infant with bronchopulmonary dysplasia and pulmonary hypertension is transported for respiratory syncytial virus infection. Which transport strategy is most appropriate?
Target an SpO2 of 85–88% to reduce oxygen toxicity
Correct the chronically elevated PaCO2 to 40 mmHg with a high ventilator rate
Give a 40 mL/kg fluid bolus to offset insensible losses from fever
Avoid hypoxemia by targeting the infant's individualized saturation goal, treat bronchospasm, and give fluids judiciously
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