This document discusses two case studies of neonatal respiratory distress. The first case involves a preterm infant with respiratory distress syndrome that was not resolving with treatment. Imaging revealed a right-sided diaphragmatic hernia. The second case involves a term infant with respiratory distress found to have a congenital cystic adenomatoid malformation of the right middle lobe on prenatal ultrasound and CT scan. In both cases, surgery was required to address the underlying anatomical issues causing respiratory distress.

1. Respiratory Distress In Neonates
• Case 1
By Dr. Randeep Singh
Resident Paediatrics
NKP SIMS and LMH, Nagpur

2. • Preterm 32 weeks gestation unbooked case delivered by normal
vaginal delivery
• Didn’t cried after birth
• Cried after bag and mask ventilation
• Shifted in NICU for prematurity, low birth weight, grunt(RDS 4)

3. • Chest X – Ray done

4. • Respiratory distress did not settled down on
nasal CPAP.
• Surfactant was given by INSURE technique
• CPAP continued.

5. • 12 hours after Surfactant therapy
• Respiratory distress persisted.
• Repeat chest X-Ray done.

6. Blood picture
 TLC – 15200
 DLC – N 65%
L 28%
E 02%
M02%
Band cells 03%(IT ratio 4%)
 Platelets – 1.71 lacs/c.mm
 CRP - Negative

7. Differential diagnosis
1. Congenital pneumonia
2. Severe RDS

8. • USG thorax –
Bilateral lung parenchyma shows heterogenous echotexture
with interspread sonographic air bronchograms which suggest
possibility of consolidation.
Also possibility of Right sided diaphragmatic hernia.

9. CT scan
Right sided diaphragmatic hernia – with liver
in Right Hemithorax

10. Congenital Diaphragmatic Hernia
• Prevalence1:2000 to 1:5000
• Male : female equal
• Right sided(20%) common in males
• 80% is left sided

11. Types 
• Posterolateral Bochdalek hernia
• Anterolateral Morgagni hernia
• Haitus hernia

12. Antenatal sonography
• Bowel loops,liver /stomach in transverse four chamber view
within thorax
• Mediastinal shift
• Hydrops fetalis
• Polyhyramnios (most commonly)
 Right sided is difficult to diagnose

13. Signs and symptoms
• Respiratory distress
• Cyanosis
• Grunt
• Decreased air entry and breath sounds
• Shift of trachea and cardiac impulse
• Abdomen flat/scaphoid

14. Associations
• Chromosomal anomelies Turners
Trisomies(13,18,21)
• CNS malformationAnencephaly
 Neural tube defect
• Congenital cardiac defectsVSD
 TOF
 TGA
• Renal anomelies Hydronephrosis
Renal agenesis

15. Imaging Studies
• Xray
• ECHO
• Renal sonography

16. MANAGEMENT
• Stabilize blood pressure (dopamine,dobutamine,
milrinone)
• Circulating volume
• Correct hypoxemia(Nitric Oxide)
• Pulmonary distress
• ECMO(conventional medical therapy are failing)

17. • Fetal surgical intervention
Fetal repair
Fetal tracheal occlusion
• Postnatal
 reduction of herniated viscera and closure of diaphragmatic defect
chest tube drainage tension pneumothorax
Ideal time for surgery is unknown(24 hours of stabilisation delays upto
7-10 days)

18. Prognosis
Poor prognostic indicators-
1. Early symptoms(symptoms after 24 hrs good prognosis)
2. Preterm
3. LBW
ABG-
Paco240mmHg, Pao2100mmHg
Oxygen Index
Compliance of lung
ECHO PPHN
Size of the diaphragm defect

19. Case 2
By Dr. Shyam kartikey Dwivedi
Resident Paediatrics
NKP SIMS and LMH, Nagpur

20. Case
• Term, Female baby/ AGA with Bwt. 3.420 kg , delivered by
Elective cesarean section (I/V/O previous scar)
• Booked case- Antenatal scan showed cystic lesion in right side
of chest
• Baby cried immediately after birth.
• APGAR score was 8/10 and 9/10 at 1 min and 5 min
respectively.

21. • Baby had respiratory distress (tachyponea, subcostal
indrawing and not maintaining saturation at room
air) & shifted to NICU for same.
• There is no H/O PROM and foul smelling liquor

22. • Examination:-
Vitals-
Normothermic
AF at level
HR- 146/min
RR- 72/min
Spo2-76% ORA
RDS- 4
CRT- <2 sec
GPE
B/L femoral well felt
No Pallor ,No icterus, acro
cyanosis present
No oedema,No dysmorphic
faces
No evidence of any congenital
anamoly
Genitals are normal

23. • S/E-
RS - chest b/l symmetrical, decreased air entry on right side of the
chest, subcostal indrawing present
CVS - S1 S2 normal, No murmur
P/A - Soft , normal shaped, no organomegaly, bowel sounds heard
adequately in all quadrants.
CNS - Cry, tone, activity good
good NNR

24. Chest X –ray after birth
Investigation
Septic Screen
CBC
Hb 16.5gm/dl
TLC 17000
DLC
N 72%,
L 20%,
E 02%,
M 03%
BAND CELL 03%(IT ratio-4%)
CRP – 0.1

25. • Probable diagnosis:
Congenital cystic adnematoid malformation

26. • Management:-
Baby immediately shifted to NICU
Feed withhold
IV access done and fluid started
O2 by nasal prone at 2ltr
Spo2 improved but distress still present
RDS 2

27. CT scan chest

28. • Immediately call to paediatric surgeon, advised
surgery.
• Right middle lobectomy (lesion was confined to Rt.
middle lobe) was done.
• After 45mins of surgery, the respiratory distress was
decreased to minimal and baby was kept on oxygen
by hood.

29. Intra Operative

31. Post Op C – X-RAY

32. Congenital Cystic Adenematoid
Malformation
• Incidence : 1-4 in 1 lakh
Histological classification
• Type 0: Acinar dysplasia, < 3% , poor prognosis
• Type 1: Macrocystic (usually cyst 2-8cm), 60%
Psuedostratified
localised only one part of one lobe
good prognosis

33. • Type 2 : Micro cystic, 20%
Multiple small cyst(<2cm)
Psuedo stratified epithelium
associated with other congenital
anomalies(renal,cardiac,diaphragmatic
hernia)
poor prognosis

34. Type 3(10%) : mixture of microcyst +
solid tissue
Cuboidal ciliated epithelium
Poor prognosis
TYPE 4(10%): Macrocystic (lack with mucus cells)
Associated with malignancy like
pleuropulmonary blastoma

35. • DIAGNOSIS : MADE IN UTERO by USG at 21 weeks (as early as
16 weeks)
• CT scan: Gives accurate diagnosis.
Clinical Feature:
Respiratory distress
Recurrent respiratory infection
Pneumothorax
Decrease breath sounds on effected side
Mediastinal shift on physical examination

36. TREATMENT
• Antenatal :1) draining the largest cyst or
placing a shunt
• 2) steroid therapy

37. Thank You