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LETTER TO THE EDITOR |
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Year : 2015 | Volume
: 8
| Issue : 4 | Page : 572-573 |
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Pneumothorax and pneumomediastinum in newborn-dreadful complications of barotrauma and rare cause of cardiac tamponade
Deepak Sharma, Srinivas Murki, Tejo Pratap Oleti
Department of Neonatology, Fernandez Hospital, Hyderabad, Telangana, India
Date of Web Publication | 14-Jul-2015 |
Correspondence Address: Srinivas Murki Department of Neonatology, Fernandez Hospital, Hyderabad, Telangana India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.160792
How to cite this article: Sharma D, Murki S, Oleti TP. Pneumothorax and pneumomediastinum in newborn-dreadful complications of barotrauma and rare cause of cardiac tamponade. Med J DY Patil Univ 2015;8:572-3 |
Sir,
A term male infant with a birth weight of 2.6 kg was delivered with an Apgar score of 3/5/7 at 1, 5 and 10 min respectively. Baby had meconium stained liquor and required endotracheal suctioning with positive pressure ventilation. The baby was extubated in the delivery room and started on hood oxygen for respiratory distress (respiratory rate of 66/min). Baby was started on synchronized intermittent mandatory ventilation mode of ventilation in view of not maintaining saturation on hood oxygen. The maximum peak inspiratory pressure (PIP) used for ventilation was 22 cm H 2 O with peak end expiratory pressure (PEEP) being 5 cm H 2 O. In view of suspecting secondary surfactant deficiency beractant, natural surfactant was given under all aseptic condition at the dose of 4 mL/kg. Echocardiography was performed, which was indicative of severe persistent pulmonary hypertension (PPHN) in the form of tricuspid regurgitation, interventricular septal deviation to the left, right to left shunt at the ductus arteriosus level and differential saturation in predoctoral and postdoctoral. In the management of PPHN, the infant was started on inotropes and latter required inhaled nitric oxide. Baby had a sudden growth in oxygen requirement (from 50% increased to 100%) with desaturation and shock, hence was evaluated with radiograph that showed right pneumothorax with pneumomediastinum [Figure 1]. Pulmonary hypoplasia was ruled out as the radiograph after birth was suggestive of well-expanded lungs with eight intercostal spaces and bilateral fluffy opacities due to meconium aspiration syndrome. Baby was managed with intercostal tube insertion, but baby sucmmed to death on day 4 of life. | Figure 1: X-ray chest showing right pneumothorax with pneumomediastinum. Note there is a shift of the mediastinum to the left
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Discussion | | |
The pulmonary air leak includes pneumothorax, pneumomediastinum, pulmonary interstitial emphysema, pneumopericardium, perivascular emphysema, subcutaneous emphysema, retroperitoneal emphysema, pneumatosis intestinalis, pneumoscrotum and rarely pneumoperitoneum and subcutaneous emphysema. This happens more frequently in the newborn period than at any other time of life as the lung parenchyma and airways are very delicate and gives way easily to increase in pulmonary pressure. All of the above-listed complications leading to the air leak syndrome take place in over-distended alveoli, which ultimately rupture. Over-distension may follow initial spontaneous vigorous respirations (usually larger term babies) at birth, high pressure with mechanical ventilation (either PEEP or PIP), vigorous ventilatory resuscitation, and air trapping in the bearing of a ball valve mechanism like meconium aspiration syndrome. [1] When the air breaks down along the perivascular connective tissue sheath toward the helm, it results in the pneumomediastinum and in the pleural space resulting in a pneumothorax. [2] These air leak syndromes must be suspected when a child suffers an unexplained deterioration in oxygenation, breathing, or cardiovascular status. [3] Diagnosis is confirmed by transillumination test and chest radiograph. [4] Handling consists of drainage of the air collection by needle aspiration or insertion of an intercostal drain. [5]
Lesson to Clinicians | | |
- Air leak syndrome is a serious complication of ventilation and must be always held in mind when there is a sudden deterioration of neonate on a ventilator as a fast diagnosis of these conditions can contribute to good neonatal outcome.
- Avoid ventilating the newborn at very high pressures as this can contribute to air leak syndrome.
- Clinicians who are ventilating the neonates must be easily prepared in putting an intercostal drain as the air leak syndrome is an emergency and must be treated with as promptly as possible.
References | | |
1. | Chernick V, Avery ME. Spontaneous alveolar rupture at birth. Pediatrics 1963;32:816-24. |
2. | Macklin CC. Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum. Arch Intern Med 1939;64:913. |
3. | Watkinson M, Tiron I. Events before the diagnosis of a pneumothorax in ventilated neonates. Arch Dis Child Fetal Neonatal 2001;85:F201-3. |
4. | Bhatia R, Davis PG, Doyle LW, Wong C, Morley CJ. Identification of pneumothorax in very preterm infants. J Pediatr 2011;159:115-20.e1. |
5. | Litmanovitz I, Carlo WA. Expectant management of pneumothorax in ventilated neonates. Pediatrics 2008;122:e975-9. |
[Figure 1]
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