Case Report: Unexpected distal airway obstruction in prematurity: a fatal case of intratracheal decidual aspiration and a call for revisiting resuscitation algorithms.

Background: Unexpected distal airway obstruction is a critical challenge during neonatal resuscitation. Aspiration of intrauterine tissue is an uncommon cause that may not respond to standard algorithms. Through comparative analysis with three previously documented cases, this report aims to clarify the clinical features, diagnostic pitfalls, and key outcomes for this entity, emphasizing the need for heightened clinical awareness and technological advances. Case presentation: A male infant was born at 30⁺⁵ weeks via vaginal breech delivery due to spontaneous preterm labor. The mother completed antenatal corticosteroids for lung maturation 4 days prior. The infant exhibited apnea and bradycardia. Standard neonatal resuscitation failed. A DOPE assessment revealed no correctable problems; a suction catheter passed easily, creating a deceptive "False-Patency" sign. Deeper suctioning yielded only scant secretions. Chest compressions began at 18 min after birth. Simultaneously, intravenous epinephrine (1:10,000) was administered every three minutes, and a resuscitation bag delivered positive-pressure ventilation. These measures continued for 42 min (until one hour of life). Approximately 60 min after delivery, with chest compressions and ventilation still in progress, two bean-sized tissue fragments were pushed out of the trachea. After removal via endotracheal tube exchange, the infant achieved return of spontaneous circulation (ROSC). Within two minutes, heart rate rose to 140 beats/minute, and SpO₂ reached 93%. Chest compressions were then halted. Histopathology confirmed decidual tissue. Despite maximal support, the infant died from irreversible multi-organ failure. Conclusion: This case illustrates that aspiration of intrauterine decidual tissue is a rare but devastating cause of unexpected distal airway obstruction in preterm infants. Findings from all four reported cases indicate that standard algorithms (MRSOPA/DOPE) are ineffective. The "False-Patency" sign-easy passage of a suction catheter despite absent chest rise and breath sounds-is a major diagnostic trap, delaying identification of a solid, peripherally impacted foreign body. A strong suspicion for this condition is critical. While specialized airway visualization instruments for preterm neonates remain a long-term goal, the primary solution lies in cognitive vigilance-specifically, recognizing this unusual condition and its misleading "False-Patency" indicator.