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Neonatal respiratory distress syndrome — USMLE Step 2 CK MCQ

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HardPediatricsNeonatal respiratory distress syndromeUSMLE Step 2 CK

A term newborn with a prenatal diagnosis of a large left congenital diaphragmatic hernia is cyanotic at delivery. Breath sounds are markedly diminished on the left, the abdomen is scaphoid, and heart sounds are displaced rightward. Which immediate respiratory strategy is most appropriate?

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Correct answer: D — Perform endotracheal intubation, gentle ventilation and gastric decompression

Congenital diaphragmatic hernia allows abdominal viscera into the thorax, producing pulmonary hypoplasia and pulmonary hypertension. Immediate intubation permits controlled, lung-protective ventilation, while an orogastric tube decompresses intrathoracic bowel. Bag-mask ventilation and noninvasive positive pressure distend the stomach and bowel, worsening lung compression. Surgical repair follows physiologic stabilization rather than occurring in the delivery room. A chest tube can injure herniated abdominal viscera and is inappropriate without evidence of pneumothorax.

Reference: Children's Hospital of Philadelphia: Infant with congenital diaphragmatic hernia clinical pathway. https://www.chop.edu/clinical-pathway/infant-cdh-pre-post-operative-care-clinical-pathway