Needle aspiration versus intercostal tube drainage for pneumothorax in the newborn

Review of risk factors, clinical manifestations, rapid diagnosis, and emergency treatment of neonatal perioperative pneumothorax

Perioperative neonatal pneumothorax (NP) is rare but very fatal. Most of the surgeries and treatments in the neonatal period are time-limited or emergent, and there are often some risk factors for pneumothorax before surgery. Physicians, surgeons and anesthesiologists need to identify possible risk factors for pneumothorax before surgery in preterm babies, patients receiving mechanical ventilation and those with underlying lung disease. The clinical presentation of NP is nonspecific, and patients may rapidly develop life-threatening complications if not promptly diagnosed and managed. This review highlights recent progress in the identification of risk factors, clinical manifestations, diagnosis and management of NP during the perioperative period.

Neonatal Pneumothorax Outcome in Preterm and Term Newborns

Background and Objectives: Pneumothorax implies the presence of air in the pleural space between the visceral and parietal pleura. The aim of this study was to investigate the incidence, clinical characteristics, risk factors, therapy and perinatal outcome in neonates with pneumothorax in a tertiary care center. Materials and Methods: A retrospective study based on a five-year data sample of neonates with pneumothorax was conducted in a Maternity Hospital with a tertiary NICU from 2015 to 2020. We included all neonates with pneumothorax born in our hospital and compared demographic characteristics, perinatal risk factors, anthropometric parameters, comorbidities, clinical course and method of chest drainage between term (≥37 GW) and preterm (<37 GW) neonates. Results: The study included 74 newborns with pneumothorax, of which 67.6% were male and 32.5% were female. The majority of women (59.5%) had no complications during pregnancy. Delivery was mainly performed via CS (68.9%). Delivery occurred on average in 34.62 ± 4.03 GW. Significantly more (p = 0.001) children with pneumothorax were born prematurely (n = 53; 71.6%) than at term (n = 21; 28.4%). Most of the neonates had to be treated with ATD (63.5%) and nCPAP (39.2%), but less often they were treated with surfactant (40.5%) and corticosteroids (35.1%). O2 therapy lasted an average of 8.89 ± 4.57 days. Significantly more (p = 0.001) neonates with pneumothorax had additional complications, pneumonia, sepsis, convulsions and intraventricular hemorrhage (68.9%). However, most children had a good outcome (83.8%) and were discharged from the clinic. Fatal outcomes occurred in six cases, while another six neonates had to be transferred to referral neonatal centers for further treatment and care. Conclusion: Significantly more children with pneumothorax were born prematurely than at term. With adequate therapy, even premature newborns can successfully recover from pneumothorax.

Safely Inserting Neonatal Chest Drains

BACKGROUND

Inserting a chest drain for a left-sided neonatal pneumothorax carries a risk of penetrating the pericardium. We identified reference ranges for the chest wall thickness (CWT) and distance between the pericardium and parietal pleura to improve safety of chest tube insertion.

METHOD

We prospectively measured the CWT using ultrasound in 20 neonates (body weight [BW] 640-2,700 g, age <10 days) at the usual site of puncture in the 4th and 5th intercostal space (ICS). Furthermore, we measured the minimal distance between the parietal pleura and the cardiac silhouette in 131 neonatal chest X-rays (birth weight, 420-4,930 g [divided into 11 weight groups]; age <10 days). Both data sets were transformed into weight-dependent percentiles (Ps). We considered the difference between the sum of P 2.5 for the CWT plus P 2.5 for pleura-heart distance minus P 97.5 for the CWT as a safe corridor for placing the tip of the needle.

RESULTS

At both ICSs, curves for the above metrics did not cross, indicating a narrow but safe corridor for each BW with at least 97.5% probability. This safety corridor was 4.6-5.2 mm wide for the 4th and 2.8-3.4 mm for the 5th ICS.

CONCLUSION

These data offer a reference for left-sided chest drain insertion for BW <2,700 g, which may help to improve safety of the procedure.

Neonatal pneumothorax from the perspective of a pediatric surgeon: classification and management protocol: a preliminary algorithm

Background/aim

Current neonatal pneumothorax classifications based on air volume escaping in pleural space have no contribution on the treatment. Therefore, our aim was to classify neonatal pneumothorax to guide treatment management based on our experiences.

Material and methods

The records of all neonates admitted to our clinics from March 2017 to August 2020 were reviewed. The patients with pneumothorax were identified through the neonatology department patient database search. The study only included the patients with symptomatic pneumothorax and these patients were evaluated into 3 groups based on the changes in peripheral oxygen saturation (SpO2) and clinical features immediately after the tube thoracostomy (TT) procedure. Accordingly, neonatal pneumothorax was divided into 3 types: patients with SpO2 increasing immediately after TT were included in type I, patients whose SpO2 did not change after TT were included in type II, and patients with SpO2 decreasing immediately after TT were included in type III pneumothorax.

Results

A total of 82 patients were included in the study. Sixty-one percent of these patients had type I, 24% had type II, and 15% had type III pneumothorax. None of the neonates died in type I and II pneumothoraces while 9 of 12 neonates (75%) died within the neonatal period in type III pneumothorax. Although we applied treatments such as high-frequency oscillatory ventilation, selective intubation, continuous negative aspiration, and surgical treatment to our patients that were lost due to type III pneumothorax, we were not successful. We successfully managed our surviving type III pneumothorax patients with a simple pressure cycle ventilator, using a combination of high rates, modest peak airway pressures [18 to 22 cm H2O and no positive end-expiratory pressure (PEEP)], and an autologous blood patch.

Conclusion

Classification of pneumothoraces into different types significantly contributes to patient treatment planning through a predetermined strategy, not through trial-and-error. High frequency and zero PEEP ventilation can provide significant improvement in risky cases.

Association between ventilatory settings and pneumothorax in extremely preterm neonates

OBJECTIVES

Pneumothorax is a catastrophic event associated with high morbidity and mortality, and it is relatively common in neonates. This study aimed to investigate the association between ventilatory parameters and the risk of developing pneumothorax in extremely low birth weight neonates.

METHODS

This single-center retrospective cohort study analyzed 257 extremely low birth weight neonates admitted to a neonatal intensive care unit between January 2012 and December 2017. A comparison was carried out to evaluate the highest value of positive end-expiratory pressure (PEEP), peak inspiratory pressure (PIP), and driving pressure (DP) in the first 7 days of life between neonates who developed pneumothorax and those who did not. The primary outcome was pneumothorax with chest drainage necessity in the first 7 days of life. A matched control group was created in order to adjust for cofounders associated with pneumothorax (CRIB II score, birth weight, and gestational age).

RESULTS

There was no statistically significant difference in PEEP, PIP, and DP values in the first 7 days of life between extremely low birth weight neonates who had pneumothorax with chest drainage necessity and those who did not have pneumothorax, even after adjusting for potential cofounders.

CONCLUSIONS

Pressure-related ventilatory settings in mechanically ventilated extremely low birth weight neonates are not associated with a higher risk of pneumothorax in the first 7 days of life.

Lung ultrasound reduces the number of chest X-rays in newborns with pneumothorax

OBJECTIVE

Aim of the study: To determine the impact of lung ultrasonography as an imaging method used to diagnose and monitor newborns with symptomatic pneumothorax and to assess the risk factors for pneumothorax and the outcomes in newborns with symptomatic pneumothorax.

PATIENTS AND METHODS

Material and methods: A single-centre retrospective study enrolled patients born after 32 weeks of gestation, with a diagnosis of pneumothorax in the first week of life. The 118 patients who were included in the study were divided into two groups. Group A (51 infants) comprised those children who were treated between 2007 and 2010, while group B (n=67) those from the years 2013 to 2016. The children from group A were monitored with repeated chest X-rays. Those from group B received repeated lung ultrasonography supported by chest X-ray in those cases where there was diagnostic uncertainty. Comparison was made between the groups with respect to pneumothorax risk factors, treatment methods and the use of imaging during the period of treatment. The statistical analysis used χ2, Mann-Whitney and Student's t-tests.

RESULTS

Results: There were no significant demographic or clinical differences between the two groups. Both the use of nCPAP (nasal continuous positive airway pressure) (p<0.001) and diagnosed perinatal asphyxia (p=0.036) were higher in group B. Congenital pneumonia occurred more often in group A (p=0.041). Earlier detection of pneumothorax (p=0.001) and shorter hospital stay (p=0.03) were observed in group B. However, the total number of imaging (lung ultrasound and chest X-ray combined) was higher (p<0.001) in group B.

CONCLUSION

Conclusion: This study confirmed the usefulness of lung ultrasound in monitoring newborns with pneumothorax, moreover significantly limiting X-ray radiation.

Needle aspiration versus intercostal tube drainage for pneumothorax in the newborn

BACKGROUND

Pneumothorax occurs more frequently in the neonatal period than at any other time of life and is associated with increased mortality and morbidity. It can be treated with either aspiration with a syringe (using a needle or an angiocatheter) or a chest tube inserted in the anterior pleural space and then connected to a Heimlich valve or an underwater seal with continuous suction.

OBJECTIVES

To compare the efficacy and safety of needle aspiration (either with immediate removal of the needle or with the needle left in situ) to intercostal tube drainage in the management of neonatal pneumothorax (PTX).

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 4 June 2018), Embase (1980 to 4 June 2018), and CINAHL (1982 to 4 June 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials and cluster trials comparing needle aspiration (either with the needle or angiocatheter left in situ or removed immediately after aspiration) to intercostal tube drainage in newborn infants with pneumothorax.

DATA COLLECTION AND ANALYSIS

For each of the included trials, two authors independently extracted data (e.g. number of participants, birth weight, gestational age, kind of needle and chest tube, choice of intercostal space, pressure and device for drainage) and assessed the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). The primary outcomes considered in this review are mortality during the neonatal period and during hospitalisation.We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

Two randomised controlled trials (142 infants) met the inclusion criteria of this review. We found no differences in the rates of mortality when the needle was removed immediately after aspiration (risk ratio (RR) 3.92, 95% confidence interval (CI) 0.88 to 17.58; participants = 70; studies = 1) or left in situ (RR 1.50, 95% CI 0.27 to 8.45; participants = 72; studies = 1) or complications related to the procedure. With immediate removal of the needle following aspiration, 30% of the newborns did not require the placement of an intercostal tube drainage. None of the 36 newborns treated with needle aspiration with the angiocatheter left in situ required the placement of an intercostal tube drainage. Overall, the quality of the evidence supporting this finding is very low.

AUTHORS' CONCLUSIONS

There is insufficient evidence to establish the efficacy and safety of needle aspiration and intercostal tube drainage in the management of neonatal pneumothorax. The two included trials showed no differences in mortality; however the information size is low. Needle aspiration reduces the need for intercostal tube drainage placement. Limited or no evidence is available on other clinically relevant outcomes.

Respiratory Care for the Ventilated Neonate

Invasive ventilation is often necessary for the treatment of newborn infants with respiratory insufficiency. The neonatal patient has unique physiological characteristics such as small airway caliber, few collateral airways, compliant chest wall, poor airway stability, and low functional residual capacity. Pathologies affecting the newborn's lung are also different from many others observed later in life. Several different ventilation modes and strategies are available to optimize mechanical ventilation and to prevent ventilator-induced lung injury. Important aspects to be considered in ventilating neonates include the use of correct sized endotracheal tube to minimize airway resistance and work of breathing, positioning of the patient, the nursing care, respiratory kinesiotherapy, sedation and analgesia, and infection prevention, namely, the ventilator-associated pneumonia and nosocomial infection, as well as prevention and treatment of complications such as air leaks and pulmonary hemorrhage. Aspects of ventilation in patients under ECMO (extracorporeal membrane oxygenation) and in palliative care are of increasing interest nowadays. Online pulmonary mechanics and function testing as well as capnography are becoming more commonly used. Echocardiography is now a routine in most neonatal units. Near infrared spectroscopy (NIRS) is an attractive tool potentially helping in preventing intraventricular hemorrhage and periventricular leukomalacia. Lung ultrasound is an emerging tool of diagnosis and can be of added value in helping monitoring the ventilated neonate. The aim of this scientific literature review is to address relevant aspects concerning the respiratory care and monitoring of the invasively ventilated newborn in order to help physicians to optimize the efficacy of care.

Effect of Needle Aspiration of Pneumothorax on Subsequent Chest Drain Insertion in Newborns: A Randomized Clinical Trial

IMPORTANCE

Treatment options for a symptomatic pneumothorax in newborns include needle aspiration (NA) and chest drain (CD) insertion. There is little consensus as to the preferred treatment, reflecting a lack of evidence from clinical trials.

OBJECTIVE

To investigate whether treating pneumothoraces diagnosed on chest radiography (CR) in newborns receiving respiratory support with NA results in fewer infants having CDs inserted within 6 hours of diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted from October 7, 2013, to December 21, 2016. The setting was 5 tertiary European neonatal intensive care units. Infants receiving respiratory support (endotracheal ventilation, continuous positive airway pressure, or supplemental oxygen >40%) who had a pneumothorax on CR that clinicians deemed needed treatment were eligible for inclusion.

INTERVENTIONS

Infants were randomly assigned (1:1) to drainage using NA or CD insertion, stratified by center and gestation at birth (<32 vs ≥32 weeks). Caregivers were not masked to group assignment. For NA, a needle was inserted between the ribs to aspirate air and was removed once air was no longer aspirated. A CD was inserted if clinicians deemed that the response was inadequate. For CD insertion, a drain was inserted between the ribs and was left in situ.

MAIN OUTCOMES AND MEASURES

The primary outcome was whether a CD was inserted on the side of the pneumothorax within 6 hours of diagnosis.

RESULTS

A total of 76 infants were randomly assigned, and 6 (4 assigned to NA and 2 to CD) were excluded because they met exclusion criteria at enrollment. Of the 70 remaining infants, 33 (16 male [48%]) were assigned to NA and 37 (22 male [59%]) to CD insertion. Their median (interquartile range [IQR]) gestational age was 31 (27-38) vs 31 (27-35) weeks, and their median (IQR) birth weight was 1385 (1110-3365) vs 1690 (1060-2025) g, respectively. Fewer infants assigned to NA had a CD inserted within 6 hours (55% [18 of 33] vs 100% [37 of 37]; relative risk, 0.55; 95% CI, 0.40-0.75) and during hospitalization (70% [23 of 33] vs 100% [37 of 37]; relative risk, 0.70, 95% CI, 0.56-0.87).

CONCLUSIONS AND RELEVANCE

Needle aspiration reduced the rate of CD insertion in symptomatic newborns with pneumothorax on CR. It should be used as the initial method of draining radiologically confirmed pneumothorax in symptomatic infants.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN65161530.

Chest tube drainage versus needle aspiration for primary spontaneous pneumothorax: which is better?

Background

Needle aspiration and chest tube drainages are two main treatments for primary spontaneous pneumothorax (PSP). However, the application of needle aspiration or chest tube drainages has not reached a consensus. The aim of this study is to compare the needle aspiration with chest tube drainages in patients suffering with PSP and therefore help offer suggestions for clinical practice.

Methods

We searched literatures from PubMed, OVID and Web of Science from their inception to June 30, 2017. Continuous and dichotomous outcomes were expressed by weight mean difference (WMD) and risk ratio (RR) respectively, and each with 95% confidence intervals (CIs). We used the fixed effect or random effect model to perform quantitative synthesis.

Results

A total of 6 RCTs recruiting 458 participants were included in our analysis. On the basis of the six studies, our results indicated that compared with chest tube drainage applying needle aspiration shortened the hospital stay (WMD: ‒1.67 days; 95% CI: ‒2.25 to 1.08; P<0.001) and decreased hospitalization rate (RR: 0.40; 95% CI: 0.22-0.75; P=0.004). However, there was no difference regarding immediate success rate (RR: 1.01; 95% CI: 0.70-1.46; P=0.96) and one-year recurrence rate (RR: 0.89; 95% CI: 0.58-1.38; P=0.61).

Conclusions

In the light of this present research, it is necessary to apply needle aspiration into treating PSP to reduce hospitalization rate and shorten hospital stay. However, the two treatments have no significant difference with respect to immediate success rate, one-year recurrence rate, one-week success rate, three-month recurrence rate or complication rate.