What is the principal treatment approach for neonatal transition failure with suspected pulmonary hypertension (PPHN)?

• A. Supportive oxygenation/ventilation with inhaled nitric oxide as indicated
• B. Antibiotics
• C. High-dose steroids
• D. Immediate ECMO for all

Answer: (A)

Neonatal transition failure with suspected PPHN is best addressed by optimizing oxygenation and ventilation while actively lowering the pulmonary vascular resistance. The frontline approach is inhaled nitric oxide, a selective pulmonary vasodilator that reduces pulmonary vascular resistance and improves oxygenation by increasing pulmonary blood flow, all while minimizing systemic hypotension. This helps lessen right-to-left shunting and improves arterial oxygen saturation, often allowing for lower ventilatory pressures.

Supportive care is essential alongside iNO: carefully adjust ventilation to maintain adequate gas exchange without causing lung injury, and ensure stable systemic perfusion to support the right heart. Antibiotics may be used if infection is suspected, but they don’t treat the pulmonary hypertension itself. High-dose steroids aren’t a standard therapy for PPHN, and ECMO is reserved for cases that do not respond to optimized medical therapy and supportive care, not as an initial step for every patient.