From the Guidelines
The best next step in management of this newborn girl with respiratory distress is endotracheal intubation (option C). This patient presents with clinical findings highly suggestive of a congenital diaphragmatic hernia (CDH), including respiratory distress, cyanosis, absent breath sounds on the left side, heart sounds shifted to the right chest, rounded chest, and flat abdomen. Immediate airway management with endotracheal intubation is crucial to stabilize the patient's oxygenation and ventilation before further interventions. Intubation will help prevent gastric distension that could worsen the compression of lung tissue by herniated abdominal contents. After securing the airway, the patient will need an orogastric tube to decompress the stomach, followed by surgical repair of the diaphragmatic defect. The other options are not appropriate initial management for this presentation:
- Antibiotics would not address the anatomical defect
- Chest tube placement could damage herniated abdominal organs
- Pericardiocentesis is not indicated without evidence of cardiac tamponade
- Prostaglandin E1 is used for ductal-dependent cardiac lesions
- Surfactant administration would not help with the mechanical compression of lung tissue in CDH. According to the American Heart Association guidelines for neonatal resuscitation 1, establishing adequate ventilation is the most important step to correct bradycardia in the newborn infant, and endotracheal intubation is often necessary to achieve this. Additionally, the use of continuous positive airway pressure (CPAP) has been studied in preterm infants with respiratory distress, but it is not the best initial management for a patient with suspected CDH 1.
From the Research
Patient Assessment
The patient is a newborn girl with respiratory distress, born 15 minutes ago by spontaneous vaginal delivery at 37 weeks gestation. The patient's vital signs are: temperature 37 C (98.6 F), pulse 176/min, and respirations 70/min. Pulse oximetry is 82% on room air. Physical examination shows grunting, subcostal and suprasternal retractions, and cyanosis of the lips and tongue.
Key Findings
- Absent breath sounds on the left and clear breath sounds on the right
- Heart sounds are loudest in the right chest
- The chest appears rounded and the abdomen appears flat
Management Options
- The patient requires immediate airway management to improve oxygenation and ventilation
- The following options are considered:
- Broad-spectrum antibiotics
- Chest tube placement
- Endotracheal intubation
- Pericardiocentesis
- Prostaglandin E1 administration
- Surfactant administration
Best Next Step
Based on the patient's presentation and the need for immediate airway management, the best next step is endotracheal intubation 2, 3, 4. This will allow for secure airway management and improvement in oxygenation and ventilation. The use of endotracheal intubation is supported by studies that demonstrate its effectiveness in emergency airway management 2, 3, 4. Additionally, the patient's high respiratory rate and low pulse oximetry reading suggest the need for prompt intervention to improve oxygenation and ventilation.
Rationale
The decision to perform endotracheal intubation is based on the patient's clinical presentation and the need for immediate airway management. The use of endotracheal intubation is supported by studies that demonstrate its effectiveness in emergency airway management 2, 3, 4. The patient's high respiratory rate and low pulse oximetry reading suggest the need for prompt intervention to improve oxygenation and ventilation. While other options, such as non-invasive positive pressure ventilation, may be considered in some cases 5, the patient's presentation suggests the need for more invasive airway management.