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A full-term male infant (39+4 weeks, 4125 g) was born following an uncomplicated pregnancy and delivery. Apgar scores were 9 and 10 and prenatal ultrasound findings were unremarkable. Within hours, he developed progressive hypoxaemia requiring escalating respiratory support. Chest radiography revealed a right middle-lobe opacity with an adjacent hyperlucent area, initially interpreted as pneumothorax, prompting chest tube insertion (figure 1A). His clinical condition deteriorated with recurrent severe desaturation events, requiring intubation, high-frequency oscillatory ventilation and multiple chest tubes for presumed air leak. Despite intensive management including inhaled nitric oxide, surfactant, corticosteroids, antibiotics and cardiovascular support, the infant remained severely hypoxic and haemodynamically unstable. Echocardiography showed normal intracardiac anatomy, a patent foramen ovale with bidirectional shunt and elevated right-sided pressures (tricuspid gradient 55 mm Hg), raising concern for persistent pulmonary hypertension of the newborn. A shunt fraction was not calculated at this stage. At 4 days of life, due to refractory hypoxic respiratory failure, the infant was cannulated for venoarterial (VA) extracorporeal membrane oxygenation (ECMO) at the referring hospital and subsequently transferred to our centre. Due to haemodynamic instability and intermittent ECMO flow challenges, he was later transitioned from peripheral VA to central venovenous ECMO. During this period, flexible bronchoscopy was performed, revealing no evidence of airway obstruction or pulmonary haemorrhage and unremarkable bronchoalveolar lavage fluid.