Neonatal Air Leak Syndromes
DR FAEZA SOOBADAR
CONSULTANT PAEDIATRICIAN AND
NEONATOLOGIST
APOLLO-BRAMWELL HOSPITAL
Air Leaks
y Pneumothorax
y Pneumomediastinum
y Pneumopericardium
p
y Pneumoperitoneum
y Subcutaneous emphysema
p y
y Pulmonary Interstitial Emphysema (PIE)
y Air embolism
P/thorax
Air embolism
PIE
Alveolar
rupture
SCE
P/mediastinum
P/peritoneum
P/pericardium
Aetiology
y Over-vigorous resuscitation
y Intubation/
/ IPPV// NCPAP
y ‘Fighting’ ventilator
y High
g PIP;; Long
g I.T
y MAS; RDS; Pneumonia; Pulmonary hypoplasia
Neonatal Pneumothorax
Incidence
y 1-1.5%
5 of all newborns
y Affects 5-14% of babies admitted to NICUs
y Males > Females
y Terms = Pre-terms
y Spontaneous
p
pneumothorax : 10/15,000
p
/ 5,
y Bilateral in 10-21%
y Mortality
y 20%
Clinical Presentation - 1
y Signs of respiratory distress: grunting, ↑RR,
y
y
y
y
recession, cyanosis
Apnoea, bradycardia, ↓BP
Displaced apex beat
Change in breath sounds
↑Ventilatory requirements
Clinical Presentation - 2
y Sudden collapse
p with severe hypotension,
yp
,
bradycardia, apnoea, hypoxia,
respiratory acidosis
Investigations
y CXR – AP, Lateral decubitus
Investigations
y CXR – AP, Lateral decubitus
y Transillumination
Investigations
y CXR – AP,, Lateral decubitus
y Transillumination
y Direct needle aspiration
p
– diagnostic
g
& therapeutic
p
Treatment - 1
Conservative therapy +/- 100% oxygen
y If no underlying
y g lung
g disease
y No complicating therapy
y No distress
y No continuous air-leaks
Resolve in 24-48
4 4 hrs
Treatment – 2
Needle aspiration
Equipment
y 21-23G
3 butterflyy needle
y Cleaning solution
y Gallipot/
p / sterile water or
y Syringe & 3-way tap
Treatment – 2
Needle Aspiration
Procedure
y Clean skin
y Insert needle 2nd/3rd ICS MCL
y End of tubing
g under water & watch for bubbles or
y Apply continuous suction to syringe until rapid flow
of air
Treatment – 3
Thoracocentesis - Equipment
y Chest drain 10 or 12FG mounted on trochar
y Sterile gown/gloves & cleaning solution
y LA, syringes & needles
y Sterile dressing pack – fine mosquito forceps,
scalpel/blade, large clamp
scalpel/blade
y Underwater seal drain
y3
3-0/4-0
0/4 0 silk suture & transparent adhesive dressing
Treatment – 3
Thoracocentesis - procedure
y Clean area & inject LA
y Make nick in skin along 4th/5th ICS MAL parallel to
rib
ib
y Use fine mosquito forceps to make track for chest
drain – just above rib below
y Insert chest drain through track about 2-3cm, having
previously withdrawn trochar from tip of chest drain
Treatment – 4
Thoracocentesis - procedure
y Place clamp on chest drain proximal to tip of
y
y
y
y
y
trochar & remove trochar completely
Connect chest drain to underwater seal drain
with 10-20 cm H2O suction pressure
R
Remove
clamp
l
and
d watch
t h for
f air
i b
bubbling
bbli outt
Suture chest drain in place
C
Cover
with
ith ttransparentt adhesive
dh i d
dressing
i
CXR
Removal of chest drain
y Lung disease has improved
y Drained no air for 24-48hrs
y Pneumothorax resolved for 24-48 hrs
y No longer requiring PIP >25
y Stop suction, clamp drain & remove on successive
days – CXRs
y Remove during expiration if spontaneous breathing;
p
if vent’d
inspiration
Complications
y Profound ventilatory & circulatory compromise &
death
y IVH
y SIADH
Pneumomediastinum
DIAGNOSIS:
DISTANT HEART SOUNDS
+VE TRANSILLUMINATION
CXR
AP – SAIL SIGN
LATERAL
TREATMENT - CONSERVATIVE
Pneumopericardium
p
CARDIAC TAMPONADE
CXR ; TRANSILLUMINATION
RX: PERICARDIAL TAPPING
HIGH MORTALITY
Audit on Neonatal Air Leaks
SSRNH NICU
31.07.2001-31.07.2007
Incidence
56/1280 (4.3%)
Gender
39 boys, 17 girls
Place of birth
SSRNH 22; JH 20; FH 7; Other 7
Mode of delivery
Em CS 15; El CS 16; NVD 24; Forceps 1
Outcome
39 alive; 17 dead (Mortality 30%)
Only 3 deaths directly attributable to airleak.
Type & site of air-leak
2 2
15
30
8
Rt p/
p/thorax
Lt p/thorax
BL p/thorax
P/mediastinum
/
P/pericardium
Birth Weight
24
25
22
20
15
Numbers
10
8
5
2
0
<1 kg
1- <1.5 kg
1.5- <2.5 kg
>=2.5 kg
Gestation & Mortality
30
28
25
20
20
15
10
8
9
4
Total
Died
4
5
Died
0
<32 wks
Total
32-<37 wks
>=37 wks
Respiratory support prior to event
8
1 2
20
7
18
CMV/SIMV
None
NCPAP
HFOV
H d ventilated
Hand
til t d
Unspecified
Underlying diagnosis & Mortality
25
22
20
15
11
10
5
0
8
4
4
Total
Died
5
3
4
3
0
1
1 1
1 1
1 1
2
Air leaks on admission = 16
3
1
8
2
1
1
RDS
Pulm hypoplasia
MAS
TTN
Pneumonia
Spontaneous
Outcome of survivors
10
Normal devt
Delayed devt
N follow-up
No
f ll
2
27
7
Summary & Recommendations
y Multiple
p aetiology
gy & not specific
p
to NICU
y Not always caused by ventilation
y Beware p
post-surfactant effect
y ? Mortality
y Very
y low rate of CP
y The undiagnosed & untreated pneumothoraces –
future approach
.
Thank
y
you