Snapshot A infant presents with signs of respiratory distress within minutes of birth. He was born at 28 weeks gestation to a diabetic mother. Vital signs are significant for a respiratory rate of 72/min. Nasal flaring and intercostal retractions are noted on exam. A diffuse ground glass appearance, as well as air bronchogram is seen on radiography. Introduction Most common form of respiratory failure in preterm infants Results from surfactant deficiency causing decreased lung compliance and atelactasis EPIDEMIOLOGY Incidence Observed in 65% of preterm infants born at 28-30 weeks of gestation Risk factors include: maternal diabetes males > females second born of twins Presentation Symptoms usually presents at birth, or immediately after birth, with symptoms including: cyanosis tachypnea nasal flaring grunting Physical exam respiratory rate > 60/min hypoxemia intercostal retractions expiratory grunting imaging CXR shows bilateral atelectasis air bronchogram classic "ground glass" appearance Differential Transient tachypnea of newborn CXR shows prominant perihilar streaking in the interlobular fissures due to retained amniotic fluids Meconium aspiration syndrome CXR findings include coarse, irregular infiltrates and hyperexpansion Congenital pneumonia CXR not useful diagnosis based on neutropenia and tracheal aspirate with Gram stain Others potential pathology includes spontaneous pneumothorax, diaphragmatic hernia, and cyanotic heart disease diagnosis Diagnosis primarily based on history, clinical presentation, and radiography gestational age maternal risk factors e.g., diabetes mode of delivery e.g., cesarean section Treatment Prevention monitor lecithin/sphingmyelin ratio and phosphotidylglycol pretreat mothers at high risk of preterm birth (34 weeks gestation or less) with corticosteroids (betamethasone) Medical management intubation/CPAP/mechanical ventilation indicated to maintain adequate oxygenation surfactant replacement indicated to increase lung compliance, reducing atelectasis shown to decrease mortality supportive care most patients remain hospitalized in the NICU for several days/weeks Complications Persistant PDA, bronchopulmonary dysplasia, retinopathy of prematurity secondary to oxygen supplementation, intraventricular hemorrhage, and necrotizing enterocolitis Prognosis Ranges widely depending on degree of prematurity and lung development Immediate, intensive care critical for survival in diagnosed cases