One-sided high-frequency oscillatory ventilation in the management of an acquired neonatal lobar emphysema: a case report and review

Selective Bronchial Occlusion for Treatment of a Bronchopleural Fistula in an Extremely Preterm Infant

Neonatal pulmonary air leak commonly occurs as a complication of mechanical ventilation in infants with underlying hyaline membrane disease. They can commonly be managed conservatively or with the application of a chest drain, but some severe cases pose a significant challenge in finding an alternative therapeutic solution. Selective bronchial occlusion represents an unconventional rescue therapy for treating bronchopleural fistula resistant to the standard therapy. A 27-week gestation preterm infant ventilated for respiratory distress syndrome developed tension right-sided pneumothorax. Conventional modalities of treatment were tried and were unsuccessful. Intermittent selective bronchial occlusion with a Fogarty’s catheter and high-frequency oscillatory ventilation resulted in considerable improvement in the infant’s clinical condition and radiographic findings.

Management of severe right lung cystic pulmonary interstitial emphysema in an infant at 24 weeks gestation with bedside selective left main stem bronchial intubation: Case report and review of the literature

Pulmonary interstitial emphysema (PIE) is a severe complication of mechanical ventilation in preterm infants. Selective bronchial intubation is a rarely used treatment strategy, as it is challenging, especially left main stem bronchial intubation. We report our experience in an infant at 24 weeks gestation with bedside left main stem bronchial intubation using flexible fiberoptic bronchoscopy. We also describe in detail the procedural details involved in the selective left main stem bronchial intubation including the helpful technique of gently bending the tip of the endotracheal tube to create "memory" to better direct the tube into the left main-stem bronchus while using the flexible fiberoptic bronchoscope. A review of the literature regarding selective bronchial intubation in newborn infants is presented. This case report and literature review suggest that bedside left main stem bronchial intubation using a flexible fiberoptic bronchoscope is a viable option to successfully manage even the most unstable extreme premature infant with unilateral right lung cystic PIE. This may potentially prevent a rare but necessary invasive surgical procedure like lobectomy or even death.

Decompression of multiple tension pneumatoceles in a child using computed tomography-guided percutaneous catheter placement

Pneumatoceles can develop as a complication of pneumonia. Air accumulation inside pneumatoceles can produce a pressure effect on surrounding structures. A 15-month-old girl who developed multiple tension pneumatoceles secondary to infection caused by pneumococcus is reported. The patient experienced severe cardiorespiratory compromise that was unresponsive to conservative treatment with high-frequency oscillatory ventilation. The condition was successfully treated with computed tomography-guided percutaneous catheter placement using a pigtail catheter for decompression. A stepwise approach was adopted for removal of the catheter.

Pneumatoceles in preterm infants-incidence and outcome in the post-surfactant era

OBJECTIVE

Pneumatoceles are gas-filled cysts within the lung parenchyma resulting mostly from ventilator-induced lung injury and air-leak in premature infants with respiratory distress syndrome. The use of surfactant in the treatment of respiratory distress syndrome has resulted in a decrease in the incidence of air-leak disease. Our aim was to study the incidence and clinical course of pneumatoceles in the surfactant era.

STUDY DESIGN

A retrospective study of infants born at < or =30 weeks gestational age was admitted to the University of Connecticut Health Center NICU from 1998 to 2007. Pneumatoceles and other intrathoracic air-leaks were identified and comparisons were made with infants without these conditions.

RESULT

Pneumatoceles were identified in 19 preterm infants, born at gestational age < or =30 weeks, needing positive pressure ventilation for respiratory distress syndrome between the years 1998 to 2007. Pneumatoceles appeared early (median, 7th day of life; range, 1st to 28th day of life) and usually resolved with decrease in mean airway pressure (median, 4 days; range, 3 to 125 days). The majority of pneumatoceles were located in the right parahilar region (18/19). Associated intrathoracic air-leaks were pulmonary interstitial emphysema (5/19), pneumothorax (10/19), and pneumomediastinum (1/19). None of the infants required any invasive procedures to alleviate the pneumatoceles. In infants who survived, most pneumatoceles resolved with a decrease in mean airway pressure or extubation (14/15). One infant had a persistent pneumatocele for 125 days without any cardiopulmonary compromise and five infants died as a result air-leaks along with other complications of prematurity.

CONCLUSION

Pneumatoceles are a manifestation of intrathoracic air-leaks of prematurity. They are markers for ventilator-induced lung injury and are associated with significant mortality similar to other intrathoracic air-leaks. However, conservative management with reduction in mean airway pressure is effective in the resolution of this condition and interventional decompression of the pneumatocele is generally not necessary.

VATS management of an enlarging multicystic pneumatocele

A multicystic pneumatocele progressively enlarged when the patient required positive pressure ventilation for an intercurrent respiratory syncytial virus infection. Video Assisted Thoracoscopic Surgery was used to visualize the pneumatocele for cannulation. One chamber of the pneumatocele was cannulated with a pigtail catheter and another large chamber ruptured, without cannulation. The multicystic pneumatocele resolved with this therapy.

Controlled-ventilation volumetric CT scan in the evaluation of acquired pulmonary lobar emphysema: a case report

Acquired lobar emphysema (ALE), a clinical entity often associated with bronchopulmonary dysplasia (BPD) in premature infants, carries significant morbidity and mortality. Because of compression of adjacent lung tissue and poor response to medical therapy, patients may require surgical resection of the hyperinflated region of lung. The decision of proceed to surgery is often problematic, relying upon standard chest radiographs, ventilation-perfusion scans, and high resolution CT (HRCT) scans. We report the use of controlled volume HRCT with breath-holding at TLC and FRC in an infant with severe BPD and ALE. Using reconstruction software, we could estimate total lung volume as well as the volume of the lobe affected by ALE at both lung volumes, permitting the determination of the degree of air trapping. This is turn afforded us confirmatory data of the extent of the affected lung, justifying surgical removal.

Percutaneous catheter evacuation of a pneumatocele in an extremely premature infant with respiratory failure

Progression of pulmonary interstitial emphysema (PIE) to single or multiple pneumatoceles is uncommon, but may be seen in extremely premature infants with respiratory distress syndrome (RDS) on mechanical ventilation, after bacterial pneumonia and after suction catheter-induced airway trauma. While most premature infants with pneumatoceles are managed conservatively, mechanical decompression may be necessary.(1-3) Prior descriptions of neonatal intensive-care management of pneumatoceles in premature infants are individual case reports. We report the case of a 1-month-old extremely premature infant with RDS and respiratory failure from superimposed respiratory syncytial viral pneumonitis, PIE, and an enlarging pneumatocele, which was successfully managed with a percutaneously placed pigtail catheter.