Acute Respiratory Distress Syndrome, Mechanical Ventilation, and Neurological Vulnerability in Neonates with Congenital Heart Disease

Abstract

Background: The postnatal transitional period represents a phase of marked hemodynamic adaptation in neonates, particularly vulnerable in those with congenital heart disease (CHD). Acute respiratory distress syndrome (ARDS) in this population may reflect circulatory instability rather than primary pulmonary pathology.
Objectives: To evaluate respiratory outcomes in neonates with CHD, focusing on the relationship between hemodynamic phenotype, ARDS development, and predictors of invasive mechanical ventilation.
Methods: We conducted a retrospective single-center study including 138 neonates with confirmed CHD admitted within the first 28 days of life. Clinical, demographic, and respiratory data were analyzed. ARDS severity, symptom burden, and prostaglandin E1 administration were evaluated as potential predictors of invasive mechanical ventilation using multivariate logistic regression.
Results: ARDS developed in 62.3% of patients, most frequently within the first day of life. The number of clinical symptoms at presentation was the sole independent predictor of ARDS (OR 2.4; 95% CI 1.84–3.14; p < 0.001). Invasive mechanical ventilation was required in 38.4% of neonates and was strongly associated with ARDS severity (OR 3.19; 95% CI 2.16–4.69; p < 0.001). These findings suggest that respiratory failure often reflects underlying hemodynamic instability during the transitional period.
Conclusions: In neonates with CHD, ARDS appears closely linked to circulatory imbalance rather than isolated lung disease. A physiology-driven approach integrating early hemodynamic stabilization with lung-protective ventilation strategies may improve outcomes in this high-risk population.