As a Respiratory Therapist or medical professional, of course, you must know how to provide care for adult patients. With that said, the importance of learning how to treat and care for infants and neonatal patients is just as essential.

This study guide covers some of the most common neonatal respiratory disorders that you should be familiar with. It contains practice questions for your benefit as well. So if you’re ready, let’s get started.

Common Neonatal Respiratory Disorders:

Neonatal Respiratory Distress Syndrome (NRDS)

Neonatal Respiratory Distress Syndrome (NRDS) is a disease that is common in premature infants when they were born with lungs that aren’t fully developed.

It is usually associated with decreased surfactant production at birth which results in severe hypoxemia.

Meconium Aspiration Syndrome

Meconium Aspiration Syndrome is a condition in a newborn that causes respiratory distress when meconium is aspirated into the lungs.

The term meconium refers to fecal matter that is passed by the fetus while in the womb and often occurs due to a lack of oxygen.

Apnea of Prematurity

Apnea of Prematurity is a disorder that occurs in preterm infants which results in frequent periods of apnea that last longer than 20 seconds.

It is caused by a physiologically underdeveloped respiratory control center in the brain and often results in bradycardia, pallor, and/or cyanosis.

Congenital Diaphragmatic Hernia

A Congenital Diaphragmatic Hernia is a disease in newborns that occurs when the diaphragm does not close completely during prenatal development.

It results in severe respiratory distress and requires immediate surgical repair.

The Respiratory Therapist will assist with intubation and mechanical ventilation. Infants with this condition may benefit from high-frequency oscillatory ventilation (HFOV). Also, ECMO may be indicated in severe cases.

Delivery Room Management

While, technically, it’s not a condition, a Respiratory Therapist must be familiar with the delivery room management of a newborn.

This includes performing an assessment of the newborn’s heart rate, respiratory rate, muscle tone, color, and reflexes.

You will also need to obtain an Apgar Score which is a system that is used to quickly determine the status of the newborn’s overall condition. A score should be obtained at the one-minute and five-minute marks after birth to determine what, if any, treatment is needed for the infant. 

If the newborn has an Apgar Score that is very low, it is considered to be a medical emergency, and resuscitation will likely be required.

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Neonatal Pulmonary Disorders Practice Questions:

1. What is Respiratory Distress Syndrome (RDS)?
A syndrome affecting premature infants that is caused by an inadequate amount of pulmonary surfactant, which leads to massive atelectasis and hypoxemia.

2. What are the symptoms of RDS?
Nasal Flaring, grunting, retractions, tachypnea, cyanosis, hypercapnia & hypoxemia.

3. What is RDS also known as?
Hyaline Membrane Disease (HMD).

4. What is Bronchopulmonary Dysplasia (BPD)?
A form of chronic lung disease seen in infants with severe RDS after prolonged positive pressure ventilation and supplemental oxygen.

5. What is Transient Tachypnea of the Newborn (TTN)?
It is a delayed clearance of fetal lung fluid which usually corrects with little more than observation. It is also called RDS Type II which is also known as “Wet Lung Syndrome”.
Persistent postnatal pulmonary edema. More common in full-term infants.

This book (in paperback format) has sample TMC Practice Questions on Neonatal/Pediatric care.

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6. What is neonatal pneumonia?
About 800,000 deaths occur worldwide from respiratory infections in newborn infants.
10% of infants in a NICU, premature affected more than term infants.

7. What are the risk factors of neonatal pneumonia?
Lower SES, teenage mothers, sexually active mothers and mothers with infection.

8. What are the causative organisms for neonatal pneumonia?
Group B Streptococcus (GBS), Escherichia coli, Klebsiella, Listeria, Staphylococcus,
Pseudomonas, Chlamydia trachomatis, and Torch syndrome like toxoplasmosis, rubella, cytomegalovirus, and herpes.

9. What is Meconium Aspiration Syndrome (MAS)?
Mostly affecting newborn infants. The presence of meconium within the lungs and infants born with meconium-stained amniotic fluid (MSAF).

10. What is Persistent Pulmonary Hypertension (PPHN)?
Clinical syndrome that occurs because of disruption in the normal perinatal fetal-neonatal circulatory transition. It is commonly called persistent fetal circulation.

11. What is Apnea of Prematurity (AOP)?
Sudden cessation of breathing that lasts for at least 20 seconds or is accompanied by bradycardia or cyanosis in an infant less than 37 weeks.

12. What are the Air Leak Syndromes?
Pulmonary interstitial emphysema, Pneumothorax, Pneumomediastinum, Pneumopericardium,
Pneumoperitoneum, Subcutaneous emphysema, and Systemic air embolism.

13. How do you get the diagnosis of air leak syndromes?
Chest X-ray, transillumination, needle aspiration of air from UAC (air embolism), ABG’s, and ECG.

14. What can increase the risk of RDS?
Maternal diabetes, multiple births, C-section, and fetal asphyxia. Males are slightly more susceptible.

15. When normally does Respiratory Distress Syndrome occur?
It occurs in 60-80% of infants <28 weeks of age.

16. What is the etiology & pathophysiology of RDS?
At less than 28 weeks there is underdeveloped alveoli and little surfactant that promotes atelectasis, and this decreases FRC and compliance. Hypoxia, hypercapnia, and respiratory acidosis occurs.

17. What are the signs of RDS?
Tachypnea, Grunting, Nasal flaring, Retractions, Diminished breath sounds, Progressive cyanosis, unresponsive to O2 treatment, and maybe hypotonic and unresponsive.

18. What are the ABGs for RDS?
Moderate to severe hypoxemia, hypercapnia, and mixed acidosis.

19. What will the chest x-ray show for RDS?
Diffuse granular opacities and ground glass appearance.

20. How can we help with the prevention of RDS?
Management of high-risk pregnancy to avoid premature birth. Avoid poorly timed cesarean section. Prevent asphyxia – antenatal and intrapartum fetal monitoring, proven resuscitation techniques. And antenatal steroid therapy.

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21. What is the treatment for RDS?
Surfactant replacement. Oxygen therapy – heated, humidified, blended for precise FIO2 titrated by 0.1%. Monitor with blood gas, pulse-oximetry; OWL protocol. Nasal CPAP is indicated if the oxygen saturation is < 85% at FIO2 40-70%. Also, NG tube for swallowed air.

22. When is mechanical ventilation indicated for the treatment of RDS?
When there is respiratory failure or apnea, i.e. if the pH is <7.20, PaCO2>60, PaO2 < 85%.

23. What are the 4 risk factors of bronchopulmonary dysplasia?
First, prematurity – gestational age, birth weight, and incomplete lung development. Next is respiratory failure. Third, hypoxia / hyperoxia-induced lung injury more likely in infants with frequent hypoxic spells. Preterm infants have fewer antioxidants to prevent injury. And last is ventilator-induced lung injury: volutrauma, increase PIP. Inflammatory cascade.

24. What is the treatment for BPD?
Minimize further lung injury, maximize nutrition, decrease oxygen consumption. Fluid management conservative, diuretics when necessary, normal Hb (transfusions). Drug therapies: bronchodilators, methylxanthines, steroids (controversial), GERD meds, pulmonary vasodilators
Nutrition: enteral, parenteral.

25. What is another name for transient tachypnea of the newborn?
“Wet lung syndrome”.

26. What is the incidence of transient tachypnea of the newborn?
It is more common after a C-section and in full-term infants.

27. What is the treatment for TTN?
Maintain adequate oxygenation and ventilation, give oxygen therapy and nasal CPAP. Last is give antibiotics to treat the infection.

28. What is the incidence of neonatal pneumonia?
10% in NICU. There is a higher incidence in the lower SES, teens, and sexually active moms.

29. What are the modes of transmission for neonatal pneumonia?
Transplacental, ascending vertical (from genital tract before, during birth – PROM), postnatal (exposure to infectious agents: people, breast milk, contaminated objects, etc.).

30. What are the risk factors for neonatal pneumonia?
Prematurity & low birth weight (LBW), prelabour rupture of membrane (PROM), maternal peripartum infection, and meconium aspiration.

31. What are the respiratory symptoms of neonatal pneumonia?
Grunting tachypnea, retractions, nasal flaring, cyanosis, apnea, and respiratory failure.

32. How can we help with the prevention of neonatal pneumonia?
Nosocomial which is the strict adherence to universal precautions, low nurse to patient ratio, decrease blood sampling, ventilator days, enteral feedings, etc. Also, hand hygiene.

33. What is the treatment of neonatal pneumonia?
Appropriate anti-infective agents, oxygen, ventilatory support, assure airway patency, continuous monitoring. Also, Pharmacotherapy: broad-spectrum antibiotics pending culture. Last is ECMO, it is when unresponsive to conventional therapy.

34. What is Respiratory Distress Syndrome (RDS)?
An acute disease of the newborn characterized by atelectasis, poor lung compliance, surfactant deficiency, tachypnea, peripheral edema, and inflammation.

35. What is the incidence of RDS?
Only affects approximately 1% of infants born in the US. It is the leading cause of death in premature infants. 10% of premature infants in the US develop RDS and 10% of those will die.
It has a higher incidence in infants with very low birth weight.

36. What are the risk factors of RDS?
Premature, maternal diabetes, hypothermia, fetal distress, more on male, second born of twins, C-section with no labor and previous child with RDS.

37. What is the pathophysiology of RDS?
Insufficient surfactant. When lack of surfactant and see-saw breathing can lead to atelectasis.
Immature cell and vascular development of the lungs.

38. What is the clinical presentation of RDS?
Usually pre-term, tachypnea, increased work of breathing (WOB), cyanosis, grunting, nasal flaring, see-saw breathing, and the heart may be enlarged.

39. What will the ABG results show for RDS?
Moderate to severe hypoxemia, hypercarbia, and mixed acidosis.

40. How to help with the prevention of RDS?
Delay delivery give maternal steroids for at least 48 hours prior to birth. 

41. What is surfactant therapy?
Surfactant combined with steroids can reduce time on ventilation. Reduces the severity of BPD (bronchopulmonary dysplasia), if it develops.

42. When is mechanical ventilation indicated for RDS?
It is indicated if: pH < 7.20, PaCO2 > 60, sats <85 at FiO2 of 40-60, and CPAP of 5-10.
If very low birth weight (<1000g) intubation maybe needed at time of delivery.

43. What are the complications of RDS?
Bronchopulmonary dysplasia, chronic lung disease, reactive airway disease, pneumothorax, and intraventricular hemorrhage.

44. What is retinopathy of prematurity?
It can lead to retinal scarring, retinal tearing and detachment, and blindness. Linked to hyperoxia that stimulates vascular endothelial growth factor.

45. What is transient tachypnea of the newborn?
A benign disease of near-term and greater infants. It is marked by respiratory distress that resolves within 72 hours (usually 24-48). It is also known as wet lung or RDS type 2.

46. What is the pathophysiology of transient tachypnea of the newborn?
Most likely caused by delayed reabsorption of fetal lung fluid which results in decreased lung compliance, decreased tidal volume, and increased dead space.

47. What will the chest x-ray show for transient tachypnea of the newborn?
Pulmonary vascular congestion, perihilar streaking, hyperinflation, and flat diaphragms.

48. What is the treatment for transient tachypnea of the newborn?
Oxygen therapy, CPAP and intubation in extreme cases. Hold feedings from infants with a RR >60. And is usually resolved in 12-24 hours and off all oxygen in 48 hours.

49. What is Meconium Aspiration Syndrome?
The presence of meconium in the tracheobronchial airways (below with vocal cords).

50. How often does Meconium Aspiration Syndrome occur?
Meconium staining in 10-15% of deliveries.

51. What is the clinical presentation of Meconium Aspiration Syndrome?
Usually term or post-term infants, maybe meconium staining, low APGAR scores, quick onset of respiratory distress, breath sounds are diminished and rales, and AP diameter is increased.

52. What will the chest x-ray show for Meconium Aspiration Syndrome?
Patchy atelectasis, hyper-expansion, opacity in severe cases, and looks like bacterial pneumonia.

53. What is the treatment for Meconium Aspiration Syndrome?
Suctioning, oxygen and mechanical ventilation.

54. What is the complications of Meconium Aspiration Syndrome?
Barotrauma, air leaks, increased intracranial pressure (ICP), and bronchopulmonary dysplasia.

55. What is neonatal apnea?
When infant stops breathing effort for >20 seconds, or any pause in breathing long enough for signs of bradycardia, cyanosis, or both in an infant younger than 37 weeks.

56. What is the clinical presentation of neonatal apnea?
Apnea, bradycardia, snoring or choking, loss of muscle tone, and cyanosis.

57. What is the treatment for neonatal apnea?
Monitoring, CPAP, bag/mask ventilation, caffeine, and avoid measures that can cause apnea.

58. What are the complications of neonatal apnea?
Infants will be discharged from the hospital with an apnea monitor. Depending on the cause, usually resolve within 36 weeks of birth.

59. What is Wilson-Mikity Syndrome?
Mild respiratory distress in the first days of life, but it is tricky. You will think things are fine, however 1-5 weeks later tachypnea and cyanosis return.

60. What is Chronic Pulmonary Insufficiency of Prematurity (CPIP)?
Immature infants partially recover from RDS but then need oxygen with apnea.

61. What is Bronchopulmonary Dysplasia?
A chronic lung disorder that is common in infants that were born prematurely.

62. What are the 3 types of Bronchopulmonary Dysplasia?
Mild, moderate, and severe.

63. What is mild Bronchopulmonary Dysplasia?
Essentially, infants are breathing room air and doing okay.

64. What is moderate Bronchopulmonary Dysplasia?
Need less than 30% oxygen.

65. What is severe Bronchopulmonary Dysplasia?
Need greater than 30% oxygen.

66. What is the incidence of Bronchopulmonary Dysplasia?
15-50% in infants weighing <1500g. Increased risk the earlier the infant is born.

67. What is the pathophysiology of Bronchopulmonary Dysplasia?
Lung immaturity, respiratory failure, PPV, inflammation, nutritional deficits, and genetic susceptibility.

68. What is the treatment for Bronchopulmonary Dysplasia?
Surfactant can improve the overall chances of survival, CPAP, when on a ventilator use low tidal volumes and short I-times, use of ECMO and HFV, nutrition, permissive hypercapnia, steroids, caffeine, bronchodilators, diuretics, and pulmonary vasodilators.

69. What are the complications of Bronchopulmonary Dysplasia?
Increased airway infections, exercise intolerance, reactive airway disease, tonsillar and adenoidal hypertrophy, vocal cord paralysis, and subglottic stenosis.

70. What are the long-term side effects of Bronchopulmonary Dysplasia?
Pulmonary hypertension, cor pulmonale, systemic hypertension, and neurological deficits.

This textbook is a great resource if you want to learn more about this topic.
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71. What is Persistent Pulmonary Hypertension of the Newborn (PPHN)?
It is characterized by systemic arterial hypoxemia secondary to elevated pulmonary resistance.
Increased pulmonary vascular resistance leads to right-to-left shunting and alterations in pulmonary vasoreactivity.

72. What is the incidence of PPHN?
It is very uncommon and only occurs in 1 or 2 per 1,000 births. More common in full term and post term infants. There is a high risk of mortality.

73. What are the primary causes of PPHN?
Anatomic malformations, genetics, and chronic stress.

74. What are the secondary causes of PPHN?
Meconium Aspiration Syndrome (MAS), heart disease, infection, and upper airway obstruction.

75. What is the clinical presentation of PPHN?
Cyanosis, tachypnea, respiratory distress (retractions, grunting, nasal flaring), and cardiomegaly. Chest X-ray is clear in the early stages, but late stages lung can be hyperexpanded.

76. What is the treatment of PPHN?
Maintain stable labs, minimal handling and noise, mechanical ventilation, mild hyperventilation for 12-24 hours, High-Frequency Ventilation (HFV), Extracorporeal Membrane Oxygenation (ECMO), sedation with fentanyl, nitric oxide, and IV magnesium.

77. What are the complications of PPHN?
Mortality rate around 40%, survival rate around 20% with ECMO or iNO, and neuro disabilities 15-60%.

78. What is Air Leak Syndromes?
Any process that allows air to leave the lungs outside the normal routes.

79. What is the incidence of Air Leak Syndromes?
Higher in preterm infants, higher in infants with RDS, MAS, and pulmonary hypoplasia.

80. What are the causes of Air Leak Syndromes?
Over distension, uneven alveolar ventilation, and air trapping.

Final Thoughts

So there you have it. As you can see, there are quite a few neonatal pulmonary disorders to be familiar with as a Respiratory Therapist. Learning and understanding each disorder now will help you provide better for years to come.

Again, hopefully, this guide can help make that process easier for you.

We have another study guide that provides multiple-choice practice questions on Neonatal and Pediatric Care that I think you would find to be helpful. Thank you so much for reading and as always, breathe easy my friend.