Preterm Infant with Severe Respiratory Distress and Intubation Difficulty

Presentation

A preterm male infant is born via cesarean delivery at 35 weeks of gestation with birth weight of 2.720 kg to a 30-year-old Gravida 3 Para 3 woman with an uneventful pregnancy, except for polyhydramnios. The infant is born nonvigorous, and T-piece positive pressure ventilation is given with improvement of the heart rate. The Apgar score is 5 and 7 at 1 and 5 minutes, respectively. He is noted to have severe respiratory distress and cyanosis, with oxygen saturations ranging from 54% to 60%, and intubation cannot be achieved even after several attempts using a small endotracheal tube of 2-mm internal diameter. Although the vocal cords are seen clearly, the endotracheal tube cannot be maneuvered beyond the cords. A nasopharyngeal tube is advanced and connected to noninvasive ventilation support with fraction of inspired oxygen of 1.0. The infant is admitted to the NICU and an on-call ear-nose-throat surgeon is urgently called. Upon examination, the infant is irritable and distressed with bilaterally decreased air entry and significant subcostal retractions. Heart examination reveals normal S1 and S2 heart sounds and grade II/VI systolic murmur over the left parasternal border. Abdominal examination is normal with bilaterally descended testes. At 30 minutes after birth, he is …