Unilateral pulmonary interstitial emphysema following pneumonia in a preterm infant successfully treated with prolonged selective bronchial intubation

Persistent Pulmonary Interstitial Emphysema With Respiratory Infection: A Clinicopathological Analysis of Six Cases and Detection of Infectious Pathogens by Metagenomic Next-Generation Sequencing (mNGS)

BACKGROUND

Persistent pulmonary interstitial emphysema (PPIE) is known to be related to mechanical ventilation and preterm. However, PPIE is also reported rarely in non-ventilated and full-term infants. Its relationship with respiratory infection is rarely reported in the literature. PPIE is difficult to diagnose and always mimics other congenital thoracic malformations (CTMs), such as congenital cystic adenomatoid malformation (CCAM).

OBJECTIVE

The objective of this study was to evaluate clinicopathological and radiographic features of PPIE with respiratory infection and to detect the possible infectious pathogens.

METHODS

From January 2011 to December 2019, six cases were confirmed pathologically with PPIE from a large cohort of 477 resected CTMs in West China Hospital of Sichuan University. Clinical and radiographic features were obtained from patients' medical records and follow-up. The present study aimed to analyze clinicopathological and radiographic features and to detect the infectious pathogens by metagenomic next-generation sequencing (mNGS).

RESULTS

The six PPIE cases included four girls and two boys, ranging from 2 months to 5 years; 100% (5/5) of the available cases were full-term and without mechanical ventilation. CCAM were suspected in 66.7% (4/6) patients; 66.7% (4/6) cases affected a single lobe, and 33.3% (2/6) cases affected both lung lobes. Clinically, all six PPIEs were presented with symptoms of respiratory infection and diagnosed with pneumonia. All six patients were treated by surgery after anti-infective treatment. The pathologic characteristics showed lung cysts with variable size along the bronchovascular bundles, the cysts had a discontinuous fibrotic wall with a smooth inner surface lined with uninucleated and/or multinucleated macrophages. Streptococcus pneumoniae was detected in patient No. 1. Human beta-herpesvirus 5 was detected in patient No. 2. Neisseria mucosa, Neisseria sicca, Prevotella melaninogenica, Prevotella histicola, and Fusobacterium nucleatum were detected in patient No. 5, and no infectious pathogen was detected in 50% (3/6, No. 3, No. 4, and No. 6) of cases.

CONCLUSION

Six rare cases of PPIE with respiratory infection were treated by surgery after anti-infective treatment. All five available cases were full-term infants without mechanical ventilation. The histological characteristics of PPIE were the wall of cysts composed of a thin layer of discontinuous fibrous tissue and lined with uninucleated or/and multinucleated macrophages.

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.

Positional treatment without mechanical ventilation in a very preterm infant with unilateral pulmonary interstitial emphysema: case report and review of the literature

Background

Pulmonary interstitial emphysema (PIE) in very low birth weight infants is a rare but severe complication. Although most of these air leaks develop in mechanically ventilated infants, they have also been reported in infants exposed only to nasal continuous positive airway pressure (CPAP). The optimal treatment for PIE is still under discussion and includes different approaches such as unilateral intubation, high frequency oscillation ventilation and even surgical lobectomy. However, as yet, there has been no report on complete resolution of unilateral PIE by positioning therapy without mechanical ventilation.

Case presentation

We report the case of a 28⁺¹gestational week twin, 990 g birth weight, Apgar 9–10-10. After stabilization with nasal CPAP the baby received surfactant by less invasive surfactant application (LISA) technique in the delivery room after 35 min of life, and continued respiratory support with nasal CPAP. At day 5 X-ray presented unilateral PIE, while pCO₂ increased from 40 mmHg to 55 mmHg and FiO₂ from 0.21 to 0.28 to achieve SpO₂ in the target range of 89–94%. The baby was treated by strict positioning on the affected hemithorax in a special splint while spontaneously breathing on High Flow Nasal Cannula (HFNC). Complete resolution of the unilateral PIE was observed after 96 h. No chronic lung disease developed.

Conclusion

For unilateral PIE in very preterm infants, positioning on the affected hemithorax without mechanical ventilation is a therapeutic option.

Early Pulmonary Interstitial Emphysema in Preterm Neonates-Respiratory Management and Case Report in Nonventilated Very Low Birth Weight Twins

Early pulmonary interstitial emphysema in extreme preterm neonates is closely linked with respiratory distress syndrome and exposure to mechanical ventilation. In severe cases, maintaining adequate gas exchange aiming to avoid further lung damage and other neonatal morbidities associated with systemic/pulmonary hypoperfusion, prolonged hypoxia, and respiratory acidosis can be challenging and requires in-depth knowledge into the pathophysiology of the disease. Herein, we report on very low birth weight twins who developed early pulmonary interstitial emphysema during noninvasive respiratory support. We further review the current evidence from the literature, specifically addressing on possible preventive measures and the respiratory management options of this acute pulmonary disease in high-risk neonates.

Development of Localized Pulmonary Interstitial Emphysema in a Late Preterm Infant without Mechanical Ventilation

Pulmonary interstitial emphysema (PIE) is not an uncommon finding in premature infants with respiratory distress who need respiratory support by mechanical ventilation. PIE has been reported in a few cases of neonates in whom either no treatment other than room air was given or they were given continuous positive end-expiratory pressure (CPAP) support. We present a case of a premature neonate who presented with respiratory distress, in whom PIE and spontaneous pneumothorax (PTX) developed while on CPAP therapy only. The patient was treated conservatively with subsequent resolution of the radiological findings and clinical improvement. No surgical intervention was required. It is important to know that PIE may develop independently of mechanical ventilation. We would like to add this case to the literature and describe the pertinent plain film and computed tomography (CT) findings of this entity, the possible mechanism of development, and the differential diagnosis. A review of the literature is also provided.

Pulmonary interstitial emphysema in adults: a clinicopathologic study of 53 lung explants

Pulmonary interstitial emphysema (PIE) is an unusual condition wherein air dissects through alveolar walls into the adjacent interstitial tissues where it forms cystic spaces with an associated inflammatory reaction. It is well described in premature infants with respiratory distress syndrome and is observed in adults, usually in association with ventilator use. The fibrotic and inflammatory appearance may mimic normal anatomic structures as well as pathologic changes such as granulomatous disease, organizing pneumonia, fibroblast foci of usual interstitial pneumonia, or lymphangiectasia. The presence of interstitial emphysema has not been well characterized in the adult population. We retrospectively reviewed 53 consecutive explanted lungs for the histologic presence of PIE, of which 19 (36%) cases were found to be positive. PIE was seen most commonly in patients with usual interstitial pneumonia. Review of the medical record for each patient revealed no correlation between the presence of PIE and duration of disease. A correlation was seen between prior ventilation and/or biopsy. These findings may indicate that PIE is a result of medical intervention; however, in the remainder of cases the disease process itself may have been a contributing factor.

Selective bronchial intubation in a preterm infant with congenital cystic adenomatoid malformation and pulmonary air leak syndrome

A preterm infant with congenital cystic adenomatoid malformation (CCAM) who developed a right-sided pulmonary air leak syndrome (pulmonary interstitial emphysema and bronchopleural fistula) following CCAM resection is reported. The pulmonary air leak syndrome was successfully ameliorated by intubating the right mainstem bronchus using a modified endotracheal tube that allowed selective ventilation of the left lung. The procedure was used successfully as rescue treatment to control the pulmonary air leak and to confirm the functional adequacy of the left lung prior to definitive operative surgery.

High-frequency oscillatory ventilation with low oscillatory frequency in pulmonary interstitial emphysema

BACKGROUND

Pulmonary interstitial emphysema (PIE) is a common respiratory illness in preterm infants associated with significant morbidity and mortality for which the ventilatory management is imperfect.

OBJECTIVES

To evaluate the impact of high-frequency oscillatory ventilation (HFOV) with a low oscillatory frequency and thus prolonged expiratory time in preterm infants with severe PIE.

METHODS

In a retrospective cohort study, preterm infants ≤30 weeks' gestation with radiological findings of severe PIE, and either high FiO2 or persistent respiratory acidosis were studied if managed on HFOV with a low frequency (5-6 Hz, inspiratory time 30%) for >24 h. Trends in physiological and ventilatory parameters were examined over the first 72 h, radiological changes noted, and in-hospital outcomes ascertained.

RESULTS

19 cases were identified and analysed in two groups: 14 with bilateral and 5 with predominantly unilateral disease. After transition to low-frequency HFOV, physiological responses were seen in both groups, in particular a rapid and sustained improvement in oxygenation in the bilateral group (mean (SD) alveolar-arterial oxygen difference at baseline: 404 ± 206 mm Hg; 4 h post-transition: 262 ± 181 mm Hg; 72 h: 155 ± 74 mm Hg; p = 0.0003). This occurred following a reduction in mean airway pressure (mean (SD) baseline: 14 ± 3.9 cm H2O; 72 h: 12 ± 2.9 cm H2O; p = 0.011). In the unilateral group, radiological resolution of PIE was observed on re-inflation following collapse of the affected lung. Overall, 15 infants survived, including 10 of the bilateral cases (71%), and all of the unilateral cases.

CONCLUSION

HFOV with a low oscillatory frequency may afford benefit in preterm babies with severe PIE.

Selective unilateral lung ventilation in preterm infants with acquired bullous emphysema: a series of nine cases

BACKGROUND AND AIMS

Immature lungs of preterm infants are particularly prone to overdistension from mechanical ventilation or continuous positive airway pressure. In these infants a localized pulmonary emphysema (PE) can develop. Conventional therapy regimens to resolve this process sometimes fail and especially in the case of bullous emphysema (BE) invasive procedures such as surgical resection of the affected lobe ultimately may be required. In the past few years we have applied selective one-sided lung ventilation, a nearly forgotten therapeutic option, in these infants with acquired BE.

METHODS

Medical charts of preterm infants in two Divisions of Neonatology, born between 1993 and 2010 with acquired BE treated with selective one-sided ventilation were reviewed. Gestational age, clinical presentation, course of disease, associated treatment, duration of ventilation and outcome of one-sided lung ventilation are recorded. Therapy was deemed successful if thereafter chest X-ray showed a permanent resolution of the BE and, in case of BPD, lung appearance was comparable to a grade < III according to Weinstein [Weinstein et al. Pediatr Pulmonol 1994; 18: 284-289].

RESULTS

Overall, nine preterm infants with a gestational age between 24 and 35 weeks and a birth weight between 500 and 3,170 g underwent one-sided lung ventilation. This intervention was started between day 12 and day 35 after birth and was continued for 24 hr to 7 days. In three cases selective intubation was performed on the left side. Two patients needed a second course of one-sided ventilation and one had three courses. Therapy was successful in seven patients, who had no recurrence of BE.

CONCLUSIONS

Selective one-sided intubation is technically challenging, in particular for the left bronchus, but seems to be feasible and helpful. If during selective intubation the affected lung lobe shows complete atelectasis for more than 48 hr the overdistension of airways probably will permanently resolve.

Pulmonary interstitial emphysema complicating pneumonia in an unventilated term infant

A case of pulmonary interstitial emphysema with pneumothorax and pneumomediastinum complicating pneumonia in a 6-week-old infant is reported. The patient had no history of resuscitation, bag and mask ventilation, nasal continuous positive airway pressure or mechanical ventilation.

Selective fiberoptic left main-stem intubation to treat bronchial laceration in an extremely low birth weight neonate

A neonate born at 24 weeks gestation developed a right tension pneumothorax that persisted despite the placement of multiple thoracostomy tubes, the use of high-frequency ventilation and postural therapy. On day-of-life 11, bedside bronchoscopy revealed a laceration at the junction of the trachea and right main-stem bronchus. Under fiberoptic guidance the left main-stem bronchus was intubated. Single-lung ventilation then was employed for 24h, after which time the pneumothorax never recurred. We postulate that the diversion of positive-pressure ventilation away from the laceration site allowed the surrounding injury-induced granulation tissue to create a seal and facilitate closure of the defect.

Acquired Nonneoplastic Neonatal and Pediatric Diseases

The lung biopsy is an established procedure to procure a pathologic diagnosis in a child with a suspected pneumonic process of undetermined etiology. Improvements in pediatric anesthesia and surgery have reduced the operative complications to a minimum. A biopsy can usually be taken through a small intercostal incision when localization is not especially important in a patient with diffuse changes (see Chapter 1). The alternative method for tissue sampling is the endoscopic transbronchial biopsy. There is less risk to the patient, but the specimen is smaller and crush artifacts from the instrument are more common.

Resolution of pulmonary interstitial emphysema following selective left main stem intubation in a premature newborn: an old procedure revisited

Pulmonary interstitial emphysema (PIE) contributes to worsening respiratory status in already compromised premature infants. Various treatments for PIE include high-frequency ventilation, postural therapy, pneumonectomy or lobectomy and selective bronchial intubation. While right main stem bronchus intubation is easy to perform at the bedside for treatment of PIE in the left lung, left main stem bronchus intubation for the treatment of right-sided PIE remains challenging and the technique was rarely reported and poorly described. In this case report, we revisit this procedure and describe successful treatment of right lung PIE with hyperinflation by selective left main stem intubation at 2 weeks of life in a 24-week-old premature infant who had respiratory distress syndrome and pulmonary hemorrhage. A detailed description is given to allow clinical bedside replication following specific anatomic landmarks.

Selective fiberoptic left main-stem intubation for severe unilateral barotrauma in a 24-week premature infant

A 24-week premature infant developed severe right-sided pulmonary barotrauma secondary to mechanical ventilation for respiratory distress syndrome (RDS). High-frequency oscillatory ventilation and permissive hypercapnia were initiated. A chest tube was placed to relieve a pneumothorax, and a catheter was inserted into an air-filled cyst for drainage. These maneuvers failed to improve the child's respiratory status. The child's left main-stem bronchus was then successfully fiberoptically intubated for single-lung ventilation in order to reduce the unilateral barotrauma. Single-lung ventilation was effectively and safely continued for 5 days, with complete resolution of the pulmonary barotrauma.