12-phase flow (12)

1. 1FRAME
   Frame by gestational age cohort (extreme <28 wk vs very 28-32 wk vs late preterm 32-34 vs term ≥37) and postnatal age; antenatal corticosteroid status; presenting work of breathing.
   inputs: gestational_age_weeks, birthweight_grams, postnatal_age_hours
   advance: GA cohort + ACS status + birthweight captured
2. 2ENTRY
   Identify trigger: clinical signs (tachypnea, grunting, retractions, nasal flaring) OR rising FiO₂ requirement OR CXR ground-glass pattern OR AOP / extubation failure in preterm.
   inputs: rr_neonate, spo2_neonate, work_of_breathing_silverman
   advance: RDS entry trigger documented
3. 3CONTEXT
   ACS course (adequate vs incomplete), maternal diabetes, chorioamnionitis, sex (male slightly higher RDS), mode of delivery (C-section without labor → higher RDS), thermoregulation status.
   inputs: antenatal_corticosteroid_course_status, maternal_diabetes_or_chorioamnionitis, temperature_neonate
   advance: Risk context documented
4. 4RED_FLAGS
   Cold stress → warm + radiant warmer + plastic wrap if preterm. Pneumothorax (sudden deterioration + asymmetric breath sounds + transillumination) → needle decompression + chest tube. Refractory hypoxemia despite FiO₂ 1.0 → echo + iNO consideration (route to neonatal.persistent-pulmonary-hypertension.v1). Sepsis coinfection features → empiric antibiotics (route to neonatal.early-onset-sepsis.v1).
   inputs: temperature_neonate, spo2_neonate
   advance: Red flags addressed; surfactant + ventilation plan in place
5. 5INITIAL_WORKUP
   Delivery-room CPAP 5-6 cm H₂O if breathing; intubate + surfactant if FiO₂ > 30% or persistent distress. CXR within first hour. ABG / CBG to anchor severity. CBC + blood culture if sepsis ambiguous. Glucose check. IV access for fluids + caffeine + antibiotics.
   inputs: cxr_neonate, abg_or_cbg_neonate, cbc_with_diff_neonate, glucose_neonate
   actions: panel.cbc, panel.abg
   advance: Imaging + labs returned; CPAP or surfactant initiated
6. 6BRANCHING_WORKUP
   Echo if pre-/post-ductal gradient or refractory hypoxemia → PPHN (route to neonatal.persistent-pulmonary-hypertension.v1). HFOV if MV failing. Pneumothorax suspected → CXR + transillumination + needle thoracentesis. Sepsis coinfection → expand antibiotics.
   inputs: echo_if_persistent_hypoxemia, blood_culture
   advance: Source-directed branches resolved or empirically covered
7. 7DIFFERENTIAL
   RDS vs transient tachypnea of newborn (TTN — typically term / late-preterm post-C-section, resolves in 24-48 h). RDS vs meconium aspiration (MAS — meconium-stained fluid, typical term/post-term, asymmetric CXR). RDS vs neonatal pneumonia / sepsis (overlapping features; CXR may show focal infiltrate). RDS vs CDH (scaphoid abdomen, mediastinal shift on CXR). RDS vs CHD (cyanotic; differential cyanosis with pre-/post-ductal SpO₂ gradient).
   advance: Mimics excluded or co-managed
8. 8RISK_STRATIFICATION
   Severity classification: mild (FiO₂ <30%, manageable on CPAP), moderate (FiO₂ 30-50%, surfactant indicated), severe (FiO₂ >50% or hypercapnia / acidosis, intubation + surfactant ± HFOV). BPD risk-stratification at 36 wk PMA for chronic-lung-disease prognosis. Calculator id `calc.silverman_andersen` not yet registered in clinical-tools-registry — rendered via flow.
   inputs: gestational_age_weeks, spo2_neonate
   advance: Severity tier set + ventilation / surfactant plan documented
9. 9TREATMENT
   Delivery-room CPAP 5-6 cm H₂O (Sweet 2022 + SUPPORT NEJM 2010 PMID 20472939). Surfactant — poractant alfa 200 mg/kg intratracheal via LISA preferred (or INSURE if LISA not feasible); max one repeat 100 mg/kg if persistent need. Beractant 100 mg/kg as alternative. Caffeine citrate 20 mg/kg IV/PO load, then 5-10 mg/kg/day maintenance for AOP / extubation support (Schmidt CAP NEJM 2007 PMID 17989382). Gentle MV / HFOV if CPAP fails. Permissive hypercapnia (pCO₂ 50-65 mmHg) acceptable to minimize VILI per Sweet 2022.
   inputs: birthweight_grams, gestational_age_weeks
   advance: Surfactant + caffeine + ventilation plan in place
10. 10DISPOSITION
    All RDS → NICU (icu) for ongoing respiratory support. Stable on minimal CPAP / low-flow O₂ + tolerating feeds + age-appropriate growth → step-down to inpatient special-care nursery. Discharge typically at 35-36 wk PMA + room-air + oral feeding + thermoregulation.
    inputs: gestational_age_weeks
    advance: NICU disposition confirmed; step-down criteria documented
11. 11MONITORING
    Continuous SpO₂ + cardiorespiratory + ETCO₂ if intubated. Serial ABG. Daily CXR if intubated; PRN if CPAP. Surfactant-redose at 6-12 h if persistent need (FiO₂ > 40%). Caffeine level if breakthrough apnea on therapeutic dose. Weight + growth + nutrition daily. BPD risk monitoring at 28 d + 36 wk PMA. Pre-discharge: hearing screen (AABR), eye exam (ROP screen), neurodevelopmental baseline.
    inputs: spo2_neonate, abg_or_cbg_neonate
    actions: panel.abg
    advance: Stable trends; weaning to room air + extubation
12. 12FOLLOWUP
    High-risk follow-up clinic at 3 + 6 + 12 + 24 mo (Bayley III at 18-24 mo). ROP follow-up per ophthalmology. Hearing surveillance. RSV prophylaxis with nirsevimab or palivizumab per AAP / ACIP. Immunization catch-up per ACIP. Lactation continued.
    advance: Outpatient follow-up scheduled; family education complete