NEONATAL PNEUMOTHORAX

 

NEONATAL NEONATAL PNEUMOTHORAX

 

DEFINITION:

Air or gas in the pleural cavity separating the visceral from the parietal pleura.

EPIDEMIOLOGY:

  • incidence: 1-2% of all newborns (asymptomatic NEONATAL PNEUMOTHORAX)
  • age of onset:
    • newborn
  • risk factors:
    • M > F (2:1)
    • Term & Post-term > Premies

DIFFERENTIAL DIAGNOSIS:

1. Spontaneous NEONATAL PNEUMOTHORAX

  • 1. Primary (Idiopathic)
  • 2. Secondary
  • 1. Respiratory
    • Congenital Cyst or Bleb
    • Congenital Lobar Emphysema
    • Cystic Adenomatoid Malformation
    • Meconium Aspiration
    • Pneumonia
    • Pulmonary Hypoplasia
    • Respiratory Distress Syndrome
  • 2. Others
    • pulmonary space-occupying lesions
      • chylothorax
      • diaphragmatic hernia
      • pleural effusion
    • thoracic abnormalities
      • asphyxiating thoracic dystrophies
      • neuromuscular disease
    • decreased amniotic fluid
      • renal agenesis
      • renal dysplasia
      • chronic amniotic fluid leak
  • 2. Traumatic NEONATAL PNEUMOTHORAX

  • 1. Iatrogenic
    • bronchoscopy
    • central line placement
    • mechanical ventilation with PEEP
    • thoracentesis
    • tracheostomy
  • 2. Chest Trauma
  • PATHOGENESIS

    1. Etiology

    • high transpulmonary pressures during the first few breaths of life
    • overinflation resulting in alveolor rupture

    CLINICAL FEATURES:

    1. Respiratory Manifestations

    1. Symptoms

  • 1. Asymptomatic
    • usually unilateral
    • decreased air entry to affected side
  • 2. Symptomatic
    • in only 0.5% of cases
    • 90% unilateral, 10% bilateral
    • sudden or gradual onset
    • irritability, restlessness, apnea
    • mild -> severe tachypnea, respiratory distress, cyanosis
  • 2. Signs

    • ipsilateral to the leak:
      • bulging of the intercostal spaces with an increased anteroposterior diameter
      • diminished or absent breath sounds
      • hyperresonant (tympanic) percussion note
    • tracheal deviation to the contralateral side

    3. Complications

  • 1. Respiratory Distress +/-
    • cyanosis
    • arrest
  • 2. Pneumomediastinum +/-
    • subcutaneous emphysema
    • tamponade of the great vessels (distended neck veins, hypotension, shock)
    • bulging of midthoracic area
    • may be asymptomatic or symptomatic
    • occurs in about 25% of cases
  • 3. Tension NEONATAL PNEUMOTHORAX
    • shock with hypotension, tachycardia, and diaphoresis
    • tracheal deviation towards the contralateral side
  • 4. Pneumopericardium
    • shock with muffled heart sounds and poor pulses
  • 5. Upon Re-Expansion
    • persistent bronchopleural fistula
    • pulmonary edema (in 10% following re-expansion)
  • 6. Others
    • pyoNEONATAL PNEUMOTHORAX (purulent effusion)
    • hemoNEONATAL PNEUMOTHORAX (bloody effusion)
    • hydroNEONATAL PNEUMOTHORAX (serous effusion)
    • pneumoperitoneum
  • 2. Other Manifestations

    • systemic manifestations of underlying disorders, i.e., Potter
    • Syndrome

    INVESTIGATIONS:

    1. Imaging Studies

    1. Transillumination

    • affected side transmits excessive light

    2. Chest X-Ray

  • 1. NEONATAL PNEUMOTHORAX
    • air in the pleural cavity is diagnostic
  • 2. Tension NEONATAL PNEUMOTHORAX
    • contralateral deviation of the larynx, trachea, and heart
  • 3. Underlying Lung Disorder
    • i.e., cystic adenomatoid malformation
  • 3. CT (Chest)

    • to rule out underlying lung disease, i.e. blebs

    4. Renal Ultrasound

    • to rule out underlying renal disease

    2. Blood Gas

    • hypoxia

    MANAGEMENT:

    1. Supportive

    • if the patient is hemodynamically and clinically stable
    • air is reabsorbed from the pleural space at a rate of 1.25% volume of the hemithorax per 24 hours
    • administration of 100% oxygen will increase the rate of resorption of nitrogen from the pleural space but this may increase the risk of retrolental fibroplasia
    • small frequent feeds to prevent gastric dilatation

    2. Chest Tube Thoractomy

    • indications for
      • severe dyspnea or respiratory distress
      • mechanically ventilated with PEEP
      • tension NEONATAL PNEUMOTHORAX

    3. Surgical Management

    1. Open Thoracotomy

    • indications for:
      • lungs remain unexpanded after 5-7 days of chest tube drainage to prevent formation of bronchopleural fistula
      • correction of an underlying lung disorder, i.e., blebs

    4. Tension NEONATAL PNEUMOTHORAX

    • administer 100% oxygen
    • insert a large-bore needle into the pleural cavity through the
    • 2nd anterior intercostal space
    • chest tube placement

     

     

    Pediatric Database - NEONATAL PNEUMOTHORAX

    Pediatric Organization - Pedbase [at] Gmail.com