A 32-week preterm neonate born by a Caesarian section is found to have a respiratory rate of 70/minute, grunting and cyanosis within half an hour of birth.

Diagnosis: Respiratory Distress Syndrome (RDS)

Based on the clinical presentation – a 32-week preterm neonate with a respiratory rate of 70/minute, grunting, and cyanosis within half an hour of birth – the most likely diagnosis is RDS. The prematurity significantly increases the risk due to insufficient surfactant production. Grunting is an attempt to maintain positive end-expiratory pressure (PEEP), and cyanosis indicates hypoxemia.

Immediate Management (First 10-15 minutes)

1. Assessment & Stabilization:

• Airway: Ensure a clear airway. Gentle suctioning of the mouth and nose to remove any secretions.
• Breathing: Provide supplemental oxygen via a head box or hood, aiming for a SpO2 of 88-92% as per the National Institute for Health and Care Excellence (NICE) guidelines. Avoid hyperoxia.
• Circulation: Monitor heart rate, blood pressure, and perfusion. Establish intravenous access for fluid administration if needed.

2. Respiratory Support:

• Continuous Positive Airway Pressure (CPAP): CPAP is often the initial mode of respiratory support, providing PEEP to keep the alveoli open.
• Surfactant Administration: Exogenous surfactant administration is a cornerstone of RDS management. It is typically given via endotracheal tube after intubation. Different surfactant preparations are available (e.g., Poractant Alpha, Beractant, Lesactant).
• Mechanical Ventilation: If CPAP fails to maintain adequate oxygenation and ventilation, intubation and mechanical ventilation may be necessary.

3. Monitoring:

• Continuous monitoring of heart rate, respiratory rate, SpO2, and blood pressure.
• Arterial blood gas (ABG) analysis to assess oxygenation, ventilation (PaCO2), and acid-base balance.

Differential Diagnosis

While RDS is the most likely diagnosis, other conditions must be considered:

• Transient Tachypnea of the Newborn (TTN): More common in infants born via Cesarean section due to delayed fluid clearance from the lungs. Usually resolves within 24-72 hours.
• Pneumonia: Congenital or early-onset pneumonia can present similarly.
• Meconium Aspiration Syndrome (MAS): Less likely given the absence of meconium staining, but should be considered.
• Pneumothorax: Can occur as a complication of RDS or mechanical ventilation.
• Cardiac Defects: Congenital heart defects can cause cyanosis and respiratory distress.

Further Investigations

• Chest X-ray: Typical RDS X-ray findings include diffuse granular opacities (ground-glass appearance) and air bronchograms.
• Complete Blood Count (CBC): To assess for infection (pneumonia) and anemia.
• Blood Culture: If sepsis is suspected.
• Arterial Blood Gas (ABG): To monitor respiratory status and guide ventilator settings.
• Echocardiogram: To rule out congenital heart defects.

Potential Complications

• Pneumothorax: Air leakage into the pleural space.
• Pulmonary Interstitial Emphysema (PIE): Air trapping in the lung interstitium.
• Bronchopulmonary Dysplasia (BPD): Chronic lung disease developing in infants requiring prolonged mechanical ventilation.
• Patent Ductus Arteriosus (PDA): Common in preterm infants and can contribute to respiratory distress.

Condition	Chest X-ray Findings	Typical Presentation
RDS	Diffuse granular opacities, air bronchograms	Preterm infant, respiratory distress, cyanosis
TTN	Perihilar streaking, fluid in the fissures	Infant born via C-section, mild respiratory distress, resolves within 72 hours
Pneumonia	Lobar consolidation, infiltrates	Fever, respiratory distress, abnormal CBC