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Pneumothorax in the neonate

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Ectopic Air Leaks

Ectopic air leaks can occur in newborn infants. There are several types:

  • Pulmonary interstitial emphysema (PIE) - air in the interstitial lung spaces. 
  • Pneumothorax - air in the pleural space. 
  • Pneumomediastinum - air in the anterior mediastinum. 
  • Pneumopericardium - air in the pericardial space. 
  • Pneumoperitoneum - air in the peritoneal cavity. 
  • Pneumoscrotum - air in the scrotum. 
  • Air embolus - air descending into pulmonary veins and disseminating throughout the blood stream. 
  • Surgical emphysema - air in the subcutaneous tissue.

Clinical Presentation

The clinical presentation of the various types of air leak syndromes are similar. In the mildest forms, pneumothorax, pneumomediastinum and pneumopericardium may be asymptomatic. However there is usually a deterioration in the baby's condition - usually sudden.

General signs include:

  • increasing oxygen and/or ventilation needs
  • agitation
  • unstable vital signs (e.g. HR ↓ SpO2 ↓)

As a tension pneumothorax develops and enlarges:

  • cyanosis develops
  • ↑ work of breathing
  • a mediastinal shift may be noted
  • diminished air entry on the affected side

In an advanced state of tension pneumothorax:

  • apnoea
  • bradycardia
  • abrupt drop in blood pressure and pulse pressure
  • unequal chest movement
  • poor peripheral perfusion

Cyanosis of the head with pallor of the trunk may occur in tension pneumothorax or pneumopericardium. Peripheral pulses are weak.

During pneumopericardium tamponade of the heart occurs:

  • cardiac output decreases
  • heart rate increases
  • perfusion becomes poor
  • blood pressure and pulse pressure drop
  • heart sounds become muffled

In air embolism:

  • air popping in the heart can be heard with a stethoscope
  • pockets of air/blood can be withdrawn from UAC

Diagnosis

Can be confirmed by:

Transillumination of the Chest

Transillumination of the chest with a fibre-optic light may diagnose a pneumothorax.

  • The room must be darkened, or a guard placed over the baby's chest. 
  • The affected side of the chest should illuminate/glow more than the non affected side.

Transillumination may be of limited value in large babies. A negative result should not delay an x-ray in a baby with a clinical picture of possible pneumothorax.

Chest Radiograph

Will assist in deciding the best chest drain placement position.

See also radiology pages on air leak syndromes

Emergency Needle Aspiration for drainage of Pneumothorax

Emergency Equipment for Needle Aspiration - Drainage of Pneumothorax

Emergency pot from pneumothorax trolley

  • Scalp vein 23 and 25 gauge butterfly needles 
  • 1 x 10ml and 1x 20ml syringe 
  • 1 alcohol wipe 
  • 3 way tap 
  • 1 small sterile specimen container

Emergency Treatment of Pneumothorax

  1. Collect emergency pneumothorax pot from resuscitation trolley. 
  2. For syringe aspiration: 
    Connect a 20ml syringe to 3 way tap then connect to butterfly needle tubing. 
    Dr/NS-ANP inserts needle into chest and aspirates air. 
    For underwater drainage:
    Fill small sterile specimen container with sterile water. 
    Hold tubing of butterfly cannula under water. 
    Dr/NS-ANP inserts needle into chest - bubbling of air underwater from end of tubing should be seen as pneumothorax drains 
    Ensure tubing is kept under water until needle is removed from baby's chest.

Emergency Needle Aspiration - Drainage of Pneumothorax - Diagram

syringe drainage

Underwater drainage

Syringe drainage Underwater drainage

References

  1. References Askin D (1997). Acute respiratory care of the neonate. Complications of positive pressure ventilation (6, p139-143). 
  2. Cates LA (2009). Pigtail Catheters Used in the Treatment of Pneumothoraces in the Neonate. Advances in Neonatal Care (9,1 p7-16) 
  3. Litmanovitz I, Carlo WA (2008). Expectant Mangaement of Pneumothorax in Ventilated Neonates. Pediatrics. Vol. 122 No. 5 November 2008, pp. e975-e979 
  4. Roberts JS, Bratton SL, Brogan TV. (1998). Efficacy and Complications ofPercutaneous Pigtail Catheters for Thoracostomy in Pediatric Patients. Chest 114;1116-1121 
  5. Molloy EJ, Walsh MC (2009). Comparison of pigtail percutaneous versus traditional chest tube thoracotomy for pneumothorax drainage in neonates. Journal of Neonatal-Perinatal Medicine.(Vol.2 No. 4 241-245) 
  6. Wood B, DubikM(1995).A New Device for Pleural Drainage in Newborn Infants. PEDIATRICS Vol. 96 No. 5 November , pp. 955-956 
  7. Wyatt TH (1995). Pneumothorax in the neonate. JOGGN March/April (p211-216) 
  8. Deacon J, O' Neil P (1999). Core curriculum for neonatal intensive care nursing. (p144-5. P682-3). 2nd edition. 
  9. Atrium Medical Corporation (www.atriummed.com)

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Document Control

  • Date last published: 10 October 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years