Neonatal air leak syndrome and the role of high-frequency ventilation in its prevention

Percutaneous Drainage for Giant Pulmonary Interstitial Emphysema in a Tiny Infant with a Birth Weight of 327 g

Giant pulmonary cyst in extremely low birth weight (ELBW) infants has been described as one of severe pulmonary diseases. Any definitive therapy for refractory cases, where conservative methods of treatments are not effective, has not been established as a standard. Herein, we report an ELBW infant with a giant pulmonary cyst cured by percutaneous drainage without any adverse events. A female infant was born with a birth weight of 327 g. Surfactant was administered on days 1 and 2 of life to treat respiratory distress syndrome. Tracheal intubation was performed and synchronized intermittent mandatory ventilation was promptly initiated following birth. On the course, right giant pulmonary cyst developed on day 9 after birth. Although we started conservative therapy, including right lateral decubitus positioning, high-frequency oscillatory ventilation, and systemic corticosteroid administration, the diameter of the cyst had reached 34 mm, and mediastinal displacement was observed on day 28 after birth when she weighed 393 g. She recovered by percutaneous drainage followed by suction with a pressure of -10 cm H 2 O under mild sedation for 3 days. We believe that percutaneous drainage can be one of the available options for unilateral pulmonary interstitial emphysema.

Case Report: Neurally adjusted ventilatory assist as an effective rescue treatment for pulmonary interstitial emphysema in extremely low birth weight infants

Pulmonary interstitial emphysema (PIE) is a complication observed in extremely low birth weight (ELBW) infants on mechanical ventilation. Despite various proposed therapeutic interventions, the success rates have shown inconsistency. Neurally adjusted ventilatory assist (NAVA) stands out as a novel respiratory support mode, offering lower pressure and tidal volume in comparison to conventional ventilation methods. In this case report, we present five ELBW infants with refractory PIE who were transitioned to NAVA ventilation. Following the switch to NAVA, all cases of PIE gradually resolved. In contrast to traditional modes, NAVA provided respiratory support with significantly lower fraction of inspired oxygen, reduced peak inspiratory pressure, diminished mean airway pressure, and decreased tidal volume within 7 days of NAVA utilization (p = 0.042, 0.043, 0.043, and 0.042, respectively). Consequently, we propose that NAVA could serve as a valuable rescue treatment for ELBW infants with PIE.

The effect of non-invasive high-frequency oscillatory ventilation on the duration of non-invasive respiratory support in late preterm and term infants with transient tachypnea of the newborn: a randomized controlled trial

Nasal continuous positive airway pressure (nCPAP) is one of the most commonly used non-invasive respiratory support modes in neonates with transient tachypnea of the newborn (TTN). Non-invasive high-frequency oscillatory ventilation (nHFOV) is a non-invasive respiratory support mode that has been increasingly used in neonatal respiratory disorders. This prospective randomized controlled study compared the efficacy of nHFOV and nCPAP in reducing the duration of non-invasive respiratory support. Late preterm and term infants > 34 weeks' gestation were included in the study. The infants were randomly assigned to receive either nHFOV or nCPAP. Treatment was started with standard settings in both groups. Infants who met treatment failure criteria were switched to nasal intermittent mandatory ventilation for further positive-pressure support. A total of 60 infants were included in the study. Thirty of these infants were included in the nHFOV group and 30 were included in the nCPAP group. The median duration of non-invasive respiratory support was not significantly different between the two groups (21 h [IQR: 16-68] for nHFOV vs 15 h [IQR: 11-33] for nCPAP; p = 0.09). However, after adjusting for potential confounders, nHFOV was associated with a shorter duration of non-invasive respiratory support than nCPAP (adjusted mean difference: 16.3 h; 95% CI: 0.7 to 31.9; p = 0.04). nHFOV was well tolerated and did not increase the risk of complications.    Conclusion: Our findings suggest that nHFOV is an effective and safe ventilation mode for late preterm and term neonates with TTN.   Trial registry: Clinicaltrials.gov (NCT03006354). Date of registration: December 30, 2016. What is Known: • nHFOV is a ventilation model that has been increasingly used for the management of RDS. • TTN is one of the most common causes of neonatal respiratory distress. What is New: • nHFOV is associated with shorter duration of non-invasive respiratory support and duration of oxygen support. • nHFOV may be a safe and effective alternative to nCPAP for neonates with TTN.

Risk factors and neonatal outcomes of pulmonary air leak syndrome in extremely preterm infants: A nationwide descriptive cohort study

Most extremely preterm infants (EPIs), who were born before 28 weeks of gestation, with pulmonary air leak syndrome (ALS) are symptomatic, often severe, and require drainage. EPIs with severe air leak syndrome (sALS) that require tube drainage or needle aspiration are at high risk of morbidities and mortality. This study aimed to investigate perinatal characteristics, morbidities, and mortality in EPIs with sALS, and to estimate the risk of mortality according to gestational age (GA). A prospective cohort study conducted from 2013 to 2020 compiled the Korean Neonatal Network database to evaluate the incidence, perinatal characteristics, and outcomes of sALS in EPIs born before 28 weeks of gestation. Among 5666 EPIs, the incidence of sALS was 9.4% and inversely related to GA. From this cohort, we compared 532 EPIs with sALS to 1064 EPIs without sALS as controls, matching the subjects by GA and birth weight. Preterm premature rupture of membranes, oligohydramnios, resuscitation after birth, low Apgar scores, repeated surfactant administration, persistent pulmonary hypertension of the newborn, and pulmonary hemorrhage were associated with the development of pneumothorax. The sALS group required a higher fraction of inspired oxygen and more invasive respiratory support at both 28 days of life and 36 weeks of postmenstrual age. The sALS group had a higher incidence of bronchopulmonary dysplasia and major brain injury. The mortality rate was higher in the sALS group than in the control group (55.3% vs 32.5%, P < .001), and the ALS group had a 1.7 times risk of mortality than the control group. More attention should be paid to sALS in EPIs because the frequency of sALS increased as GA decreased, and the risk of mortality was more significant at lower GA.

Incidence of Air Leak Syndrome in Pediatric Patients With SARS-COV-2 Pneumonia and Respiratory Failure: A Single-Center Retrospective Study

Air leak syndrome (ALS) is defined as the extrusion of air from an aerated compartment into an unaerated compartment with associated symptoms of respiratory distress. This syndrome can occur as a consequence of trauma, iatrogenic causes, or spontaneously. Retrospective investigations conducted in the adult population have demonstrated an elevated risk of spontaneous ALS development in patients with coronavirus disease 2019 (COVID-19) pneumonia, along with its correlation with mortality. However, no studies have yet explored this phenomenon within the pediatric population. In light of this knowledge gap, we conducted a retrospective chart review comprising 128 pediatric patients ranging in age from one month to 18 years. The primary objective was to assess the incidence of ALS in two distinct groups: patients diagnosed with COVID-19 pneumonia and those with non-COVID-19 viral pneumonia. The groups were compared using Fisher's exact test for sex, the presence of ALS, the requirement of extracorporeal membrane oxygenation (ECMO), and death. The modified Wald method was used to calculate the 95% confidence interval for the mortality rate in patients with COVID-19 pneumonia in the presence of ALS. Our findings revealed a higher prevalence of ALS in patients with COVID-19 pneumonia compared to the non-COVID-19 viral pneumonia group, with a statistically significant P-value of 0.02 and an odds ratio (OR) of 6.72. In terms of mortality rates, there was a statistically significant difference between the two groups (P = 0.025, OR = 1.083). In addition, in patients with ALS in the presence of COVID-19 pneumonia, the mortality rate was 37.5%. However, the requirement of ECMO was not statistically significant (P = 0.16, OR = 1.04). These results suggest that patients with COVID-19 pneumonia have an increased mortality rate and a heightened risk of developing ALS compared to individuals with other viral pneumonias. Furthermore, the presence of ALS was associated with a high mortality rate in COVID-19 pneumonia patients. However, it is crucial to note that obtaining a larger patient sample and involving multiple institutions would be necessary to obtain more consistent and robust data.

Risk factors for air leakage during invasive mechanical ventilation in pediatric intensive care units

Purpose

This study aimed to investigate air leakage during invasive mechanical ventilation (IMV) in a pediatric intensive care unit (PICU) and explore potential risk factors.

Methods

We conducted a retrospective cohort study of children who underwent IMV in a single-center PICU in a tertiary referral hospital. Air leakage risk factors and factors associated with an improved outcome were assessed.

Results

A total of 548 children who underwent IMV were enrolled in this study. Air leakage occurred in 7.5% (41/548) of the cases in the PICU. Air leakage increased the duration of IMV and hospitalization time. Multivariate logistic regression analysis showed a higher risk of air leakage during IMV for PICU patients with acute respiratory dyspnea syndrome (ARDS) (OR = 4.38), a higher pediatric critical illness score (PCIS) (OR = 1.08), or a higher peak inspiratory pressure (PIP) (OR = 1.08), whereas the risk was lower for patients with central respiratory failure (OR = 0.14). The logistic model had excellent predictive power for air leakage, with an area under the curve of 0.883 and tenfold cross-validation. Patients aged between 1 and 6 years who were diagnosed with measles or pneumonia and had a low positive end-expiratory pressure (PEEP) or high PaO2/FiO2 ratio were associated with improved outcomes. Patients diagnosed with central respiratory failure or congenital heart diseases were associated with less desirable outcomes.

Conclusions

Patients with ARDS, a higher PCIS at admission or a higher PIP were at higher risk of air leakage.

A case of recurrent pneumothoraces in a newborn

Pneumothoraces are not an uncommon finding in the newborn period. Recurrent pneumothoraces can be associated with complications of prematurity or use of ventilators but can be seen in rapidly progressive cystic lung disease. We report a case of recurrent pneumothoraces in an infant with the rapidly progressive cystic disease in the setting of an absent right pulmonary artery. The patient ultimately underwent pneumonectomy for definitive management of the recurrent unilateral pneumothoraces.

Pulmonary air leak syndrome in rheumatoid arthritis patient

Pulmonary air leak syndromes involve dissection of air out of the normal pulmonary airspaces and include pulmonary interstitial emphysema, pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum, subcutaneous emphysema and systemic air embolism. It presents as a spontaneous extension of dissecting air without a history of a procedure or penetrating injury. Pulmonary air leak syndromes are extremely rare complications of systemic autoimmune connective tissue diseases. Few cases were reported in the literature regarding rheumatoid arthritis patients. The purpose of this article is to emphasize on this rare pulmonary complication and discuss the physiopathology of the disease and the different risk factors for a better management of these patients. We report the case of a 45-year-old female, with a history of proven rheumatoid arthritis under methotrexate and steroids, who presented with a spontaneous dissecting subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum. The patient’s condition improved after chest drainage and adjustment of her medical treatment.

Application of ultrasonography in neonatal lung disease: An updated review

Lung disease is often life-threatening for both preterm and term newborns. Therefore, an accurate and rapid diagnosis of lung diseases in newborns is crucial, as management strategies differ with different etiologies. To reduce the risk of radiation exposure derived from the conventionally used chest x-ray as well as computed tomography scans, lung ultrasonography (LUS) has been introduced in clinical practice to identify and differentiate neonatal lung diseases because of its radiation-free characteristic, convenience, high accuracy, and low cost. In recent years, it has been proved that LUS exhibits high sensitivity and specificity for identifying various neonatal lung diseases. Here, we offer an updated review of the applications of LUS in neonatal lung diseases based on the reports published in recent years (2017 to present).

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.

Preeclampsia was a risk factor for pulmonary interstitial emphysema in preterm infants born ≤32 weeks of gestational age

AIM

This study determined the prenatal and postnatal risk factors for pulmonary interstitial emphysema (PIE) in preterm infants born at up to 32 weeks of gestational age (GA) and their contribution to severe complications.

METHODS

We studied 179 preterm infants, who had undergone chest X-rays during the first five days of life at Justus Liebig University Giessen, Germany, between 2016 and 2017. Of these, 33 were retrospectively classified as PIE and 146 as non-PIE. The PIE cases were also matched with 33 non-PIE cases by GA and gender. Risk factors were identified by univariate analyses and multivariable logistic regression.

RESULTS

Previously known risk factors for pulmonary interstitial emphysema were confirmed, including GA and birthweight and the associations with adverse outcomes like intraventricular haemorrhage and mortality. We identified preeclampsia and haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome as additional risk factors for PIE (P = .027), and lung impairment was associated with respiratory distress syndrome (P = .001), higher maximum inspired oxygen (P = .014) and needing surfactant (P = .006).

CONCLUSION

Preeclampsia and HELLP syndrome were identified as possible additional risk factors for PIE in preterm infants. These conditions should be included in future studies, to identify preterm infants at risk of PIE straight after birth.

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.

Unilateral neonatal pulmonary interstitial emphysema managed conservatively: A case report

BACKGROUND

Pulmonary interstitial emphysema (PIE) is a pathological state when air escapes from ruptured alveoli and is trapped along the sheaths surrounding the bronchovascular bundle. PIE is not uncommon in infants who require mechanical ventilation and even less common in infants on noninvasive ventilatory support; however, it is extremely unusual in infants in room air.

CASE PRESENTATION

A 2-week-old male infant developed worsening tachypnea in the special-care nursery. The patient was born at 33 weeks' gestation by induced vaginal delivery due to pre-eclampsia. He required positive pressure ventilation at birth and was admitted to the neonatal intensive care unit on nasal continuous positive airway pressure. On the second day of life, exogenous surfactant was administered via endotracheal tube due to increased oxygen requirement, and, soon after, he was weaned off all respiratory support. After 10 days of stability, he developed tachypnea with diminished air entry on the left side of the chest. Chest radiograph and chest computerized tomography confirmed left-sided unilateral PIE. The patient was treated conservatively with positional therapy alone. Significant clinical and radiographic improvement was noticed within 4 days; almost complete resolution by 10 days and the infant was discharged 23 days later. At follow-up at 7 months, the infant was found to be symptom-free with a normal chest radiograph.

CONCLUSIONS

Traditional management of unilateral PIE generally involves a combination of invasive ventilatory support and positional therapy to break the vicious cycle pathophysiology of PIE. This report focuses on the insidious progression of PIE in nonventilated neonates and describes a nontraditional conservative management strategy for the management of unilateral PIE.

Idiopathic pneumoperitoneum without gastrointestinal perforation in a low-birth weight infant: A rare type of air leak syndrome

Neonatal free air on X-ray images is generally due to intestinal perforation, and requires surgical intervention. However, some cases without intestinal perforation show free air on X-ray images. Pneumoperitoneum without perforation is caused by an air leak syndrome. We present here the case of a low-birth-weight infant with free air on X-ray images, who had no evidence of intestinal perforation intraoperatively.

Use of high frequency oscillatory ventilator in neonates with respiratory failure: the clinical practice in Taiwan and early multimodal outcome prediction

High-frequency oscillatory ventilation (HFOV) can be a rescue for neonates with refractory respiratory failure or an early elective therapy for preterm infants with severe respiratory distress syndrome (RDS). However, little is known about the current evolution and therapeutic limitations of HFOV. We therefore aimed to describe its use in clinical practice and predict the risk of mortality for neonates receiving HFOV. A retrospective observational study of all neonates treated with HFOV in a quaternary referral NICU between January 2007 and December 2016 was conducted. We classified these patients into five subgroups based on primary respiratory diagnoses. We performed the logistic regression and decision tree regression analyses to identify independent factors of 30-day mortality following HFOV. A total of 1125 patients who were ever supported on HFOV were enrolled, of whom 64.1% received HFOV as a rescue therapy, 27.2% received it as an elective therapy, and 8.7% received it for air leak. An average oxygenation index (OI) greater than 25 in the first 24 hours after the initiation of HFOV and patients with secondary pulmonary hypertension were found to have the greatest risk of in-hospital mortality (p < 0.0001). The overall in-hospital mortality rate was 25.8% (290/1125). Decision tree regression analysis revealed that neonates with refractory respiratory failure who had a pre-HFOV OI value higher than 20.5 and OI values higher than 21.5, 23.5 and 34 at 2 hours, 6 hours, and 12 hours after the use of HFOV, respectively, had a significantly increased risk of 30-day mortality. We identified the predictors and cutoff points of OI before and after the initiation of HFOV in neonates with respiratory failure, which can be clinically used as a reference for 30-day mortality. Further efforts are still needed to optimize the outcomes.

Pigtail catheters versus traditional chest drains for pneumothorax treatment in two NICUs

Pneumothorax in newborns can be life-threatening. The traditional treatment of pneumothorax is chest drain placement. Recently, modified pigtail catheter has been proposed as a less traumatic approach despite limited experience in infants. To compare the effectiveness and safety of pigtail catheters versus traditional straight chest drains in term and preterm infants with pneumothorax, in two tertiary neonatal units: Policlinico Hospital in Bari, IT and John Radcliffe Hospital in Oxford, UK. We retrospectively reviewed medical records of 47 newborns with pneumothorax admitted to the two units between October 2009 and June 2017, and treated with either pigtail catheters or straight chest drains. Three newborns (6.7%) were excluded from the study because they were treated with both types of drains. The remaining 44 neonates were included in the analysis. Overall, 56.8% (n = 25/44) of pneumothoraces were drained with pigtail catheters and 43.2% (n = 19/44) with straight drains. No differences in gestational age and birth weight were found. The success rate, defined as complete radiological resolution of the pneumothorax after drainage, was significantly higher in the pigtail group (96.0% versus 73.7%; p < 0.05). Days of drainage, length of hospital stay and duration of respiratory support were not significantly different. Subcutaneous emphysema and drain dislodgement/malfunction occurred only in the straight drain group (0.0% versus 11.1%; p = 0.181). No significant differences in mortality between the two groups were found (28.0% pigtail group versus 26.3% straight drain group; p > 0.05).Conclusion: Pigtail catheters are a safe and effective alternative to traditional chest drains for infants with pneumothorax. What is Known:• Air leaks in newborns can represent an emergency, especially among preterms;• The first treatment in a life-threatening pneumothorax is thoracentesis with needle aspiration or placement of a chest drain.What is New:• Pigtail catheter have been described as an alternative to traditional chest drains;• Pigtail catheters are a safe and effective alternative to traditional chest drains for infants with pneumothorax.

Nontraumatic tension pneumopericardium in nonventilated pediatric patients: a review

BACKGROUND AND AIMS

Pneumopericardium is a rare air leak syndrome caused by the abnormal presence of air in the pericardial sac, with a high risk of morbidity and mortality. It is clinically divided into nontension and tension pneumopericardium, with the latter resulting in a decreased cardiac output and circulatory failure. There are limited data regarding nontraumatic pneumopericardium in nonventilated pediatric patients. Therefore, we aimed to describe a case of tension pneumopericardium and review the available literature.

METHODS

Case report and literature review of nontraumatic pneumopericardium in nonventilated pediatric patients.

RESULTS

A 2-month-old infant developed cardiac tamponade secondary to tension pneumopericardium 11 days after cardiac surgery promptly resolved with pericardium drainage. We reviewed the literature on this topic and retrieved 50 cases, of which 72% were nontension whereas a minority were tension pneumopericardium (28%). Patients with tension pneumopericardium were mostly neonates (35.7% vs 22.2%), presented with an isolated air leak (64.3% vs 36.1%), and had a history of surgery (28.6% vs 8.3%) or hematological disease (28.6% vs 11.1%). In all nontension cases, treatment was conservative, whilst in all other cases, pericardiocentesis/pericardium drainage was carried out. There was a high survival rate (86.0%), which was lower in patients with tension pneumopericardium (71.4% vs 91.6%).

CONCLUSIONS

Pneumopericardium is a rare condition with a higher mortality rate in patients with tension pneumopericardium, which requires immediate diagnosis and treatment. In nonventilated patients, tension pneumopericardium occurred more frequently in neonates, as an isolated air leak, and in those with a history of surgery or hematological disease.

Neonatal Respiratory Support on Transport

Respiratory support is frequently required during neonatal transport. This review identifies the various modalities of respiratory support available during neonatal transport and their appropriate clinical uses. The respiratory equipment required during neonatal transport and appropriate safety checks are also reviewed. In addition, we discuss potential respiratory emergencies and how to respond to them to decrease the risk of complications during transport and improve health outcomes.

Risk factor analysis of pneumothorax associated with persistent pulmonary hypertension of the newborn in Thai neonates

Objective: To determine the risk factors and outcomes of persistent pulmonary hypertension of the newborn (PPHN)-associated pneumothorax (PTX).Study design: The medical records of infants diagnosed with PPHN with or without PTX from January 2012 to July 2017 were retrospectively reviewed.Results: Of the 102 included PPHN infants, PTX was found in 32 (31.4%) infants with 43.8% (14/32) mortality. PTX was significantly associated with increased mortality with an odds ratio (OR) of 5.27 (95% confidence interval [CI] 1.96-14.17). Unilateral PTX was more common than bilateral PTX (53.1 versus 46.9%, respectively). Multivariate logistic regression analysis indicated that a 1-minute Apgar score of ≤7 was associated with an increased risk for PTX (adjusted OR = 2.67 [95% CI 1.14-6.25]). In subgroup analysis, each increase of maximum peak inspiratory pressure (PIP) of 1 cmH₂O significantly increased the odds of PTX by 1.46 (95% CI 1.02-2.07), while each 1 mmHg increase in arterial partial pressure of oxygen (P_aO₂) decreased the odds of PTX (adjusted OR = by 0.98 [95% CI 0.97-0.99]).Conclusions: PTX was significantly associated with higher mortality in PPHN infants. Lower Apgar score and increasing PIP in conventional mechanical ventilation were risk factors for PTX. Higher P_aO₂ was associated with a decreased rate of PTX.

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.

Pneumopericardium in the Neonate

Pneumopericardium occurs when air accumulates in the pericardial sac surrounding the heart and is one of the rarest forms of air leaks in neonates. Because of various advances in neonatal care, including gentler modes of ventilation, surfactant replacement, and antenatal steroids, the incidence of pneumopericardium has decreased. Despite the decrease in incidence of pneumopericardium, most cases arise in premature infants with a history of respiratory distress and mechanical ventilation. Evidence has shown that the incidence is inversely related to birth weight and that pneumopericardium has high mortality and morbidity rates.

The Heart's Halo: Caring for Pediatric Pneumopericardium

Pediatric pneumomediastinum and pneumopericardium (PPC) are rare complications, which can arise from various etiologies. We report a case of pediatric PPC secondary to an asthma exacerbation and discuss relevant diagnostic and management principles. Physicians must be aware of PPC and its implications due to the high mortality rate. PPC patients require close observation with continuous cardiorespiratory and telemetry monitoring, and providers experienced in the management of cardiac tamponade at a center capable of providing cardiothoracic surgical intervention. Time to resolution is multifactorial, but can be achieved promptly with supportive care and treatment of underlying condition.

A case of significant subcutaneous emphysema on non-invasive respiratory support in a late preterm infant

Air leaks are known complications associated with mechanical ventilation, with a higher incidence in more premature babies. Pneumothorax and pneumomediastinum are the most common ones and the majority would resolve spontaneously without active intervention. Subcutaneous emphysema is very rare, with few reported cases in neonates. We report here a case of extensive subcutaneous emphysema, pneumothorax and pneumomediastinum in a late preterm baby developed while on nasal continuous positive airway pressure (nCPAP) respiratory support.

Management of pneumothorax in hemodynamically stable preterm infants using high frequency oscillatory ventilation: report of five cases

Background

Despite an increased use of non-invasive ventilatory strategies and gentle ventilation, pneumothorax remains a common complication in preterm infants. The ventilator management of infants with air leaks remains challenging in terms of both prevention and treatment. Recently the safety and efficacy of expectant management avoiding chest tube drainage to treat large air leak in preterm infants hemodynamically stable has been reported.

Case presentation

In the present study, we report five cases of preterm infants with birth weight ≤ 1250 g affected by respiratory distress syndrome and treated with nasal continuous positive airway pressure as first intention. They were intubated for worsening of respiratory distress with increasing oxygen requirement and concomitant increase of respiratory rate and P_CO2 values due to occurrence of pneumothorax, and they were successfully treated using high-frequency oscillatory ventilation without chest tube insertion.

Conclusion

In our experience high-frequency oscillatory ventilation provided a conservative management of a significant pneumothorax in preterm newborns hemodynamically stable and requiring mechanical ventilation. This approach allowed us to avoid the increasing of air leak and the insertion of chest tube drainage and all the subsequent associated risks.

Successful rescue combination of extracorporeal membrane oxygenation, high-frequency oscillatory ventilation and prone positioning for the management of severe methicillin-resistant Staphylococcus aureus pneumonia complicated by pneumothorax: a case report and literature review

BACKGROUND

To describe the experience of combination therapy with extracorporeal membrane oxygenation(ECMO), high-frequency oscillatory ventilation(HFOV) and prone positioning in treating severe respiratory failure caused by community acquired methicillin resistant Staphylococcus aureus(CA-MRSA).

CASE PRESENTATION

A 30-year-old female presented with fever and dyspnea for 3 days. She was diagnosed CA-MRSA pneumonia complicated by severe respiratory failure, pneumothorax and neutropenia. Venovenous ECMO was applied within 8 h of the pneumothorax diagnosis. For amelioration of ventilator-induced lung injury, HFOV and prone positioning were combined with ECMO. The patient's condition improved considerably. ECMO was weaned on day 19, and she was discharged on day 48 with good lung recovery.

CONCLUSIONS

To the best of our knowledge, this was the first case in which ECMO was combined with HFOV and prone positioning to treat severe necrotic CA-MRSA pneumonia complicated with pneumothorax. This combination therapy may provide safe respiratory support, may minimize the risk of barotrauma, and provide better drainage of secretions in patients with necrotizing pneumonia.

Development of pulmonary air leak in an extremely-low-birth-weight infant without mechanical ventilation: a case report

A 34-year-old woman at 25 weeks 3 days was diagnosed with preterm labor and underwent an emergency cesarean section. The neonate did not cry or show any activity. The heart rate was 80 beats/min and the oxygen saturation on pulse oximetry (SpO₂) was 77%. Immediately, positive pressure ventilation was delivered by T piece resuscitator, and then anesthesiologist performed endotracheal intubation. The neonate demonstrated severe cyanosis and the SpO₂ dropped to 30%. Ventilation was not successful even after intubation, and we found neck crepitus, chest wall distension, and severe cyanosis on physical examination. We suspected tension pneumothorax and performed needle thoracentesis. The neonate was stabilized and transferred to the neonatal intensive care unit for further treatment, but expired on the 10th day of life. We report a case of pulmonary air leak developing tension pneumothorax, pneumomediastinum, subcutaneous emphysema in an extremely-low-birth-weight preterm infant immediately after birth.

A Case of Pulmonary Interstitial Emphysema Treated by Percutaneous Catheter Insertion in Extremely Low Birth Weight Infant

The pulmonary interstitial emphysema (PIE) is a life-threatening illness in premature infants with mechanical ventilation. While most are managed conservatively, decompression would be necessary. Here, we report the first case of PIE treated by percutaneous catheter insertion in an extremely low birth weight (ELBW) infant in Korea. The patient, born with 660 g in 23+2 weeks of gestation, showed PIE in left lower lung on postnatal day 12. Percutaneous catheter insertion was performed on postnatal day 25. The size of PIE decreased, but didn't disappear completely. On postnatal day 42, we exchanged catheter and inserted additional catheter in pleural space. However, sudden desaturation and pneumothorax occurred on postnatal day 44. We changed catheter in pleural space, and pneumothorax and PIE improved. Finally, we successfully removed catheters, and weaned patient out. As in our case, percutaneous catheter insertion would be a useful option for ELBW infants with PIE.

Pigtail catheters versus traditional chest tubes for pneumothoraces in premature infants treated in a neonatal intensive care unit

BACKGROUND

Pneumothorax is more frequent in the neonatal period, especially among premature infants. Pigtail catheters have been shown to be as effective as and less invasive than traditional chest tubes in adults; however, data regarding premature infants are limited. We aimed to compare the efficacy, safety, and complications associated with the placement of traditional chest tubes versus pigtail catheters in premature infants with pneumothoraces.

METHODS

We retrospectively reviewed the medical records of premature infants with pneumothorax seen in the neonatal intensive care unit of a single medical center over a period of 11 years, who were treated with either traditional chest tubes or pigtail catheters. Changes in the vital signs before and after the procedures were recorded in both groups. Data on age, sex, clinical presentation, procedure time, subsequent therapies, hospital days to discharge, success rate, and complications of the procedures were collected from medical records and compared between the two methods of intervention.

RESULTS

Eighty-six thoracostomies, including 60 pigtail catheters and 26 traditional chest tubes, were performed in 66 premature infants. The success rate, demographics, days of tube insertion, length of hospital stay, days of mechanical ventilation, type of oxygen supply, and insertion-related complications were not significantly different between the two groups. Pigtail catheter insertion required a shorter procedure time than the traditional chest tube insertion (14.92 minutes vs. 25.31 minutes, respectively, p < 0.001).

CONCLUSION

Pigtail catheters are a safe and effective alternative to traditional chest tubes for premature infants receiving treatment for pneumothoraces in a neonatal intensive care unit. Placement of pigtail catheters is an easy and quick bedside procedure and is particularly useful for premature infants who require immediate air drainage.

Pneumomediastinum in the neonate

A pneumomediastinum is an air leak in which the free air is concentrated in the mediastinum. Although most neonatal pneumomediastinums do not require intervention, complications such as subsequent air leaks can arise. Proper radiologic identification, as well as an understanding of the anatomy and pathophysiology associated with a pneumomediastinum, are necessary for an accurate understanding and diagnosis. This article will review the interpretation of radiologic findings in a neonate with a pneumomediastinum.