PEDIATRIC RESUSCITATION PNEUMOTHORAX

pediatric resuscitation pneumothorax
Air leak syndromes are disorders produced when a rupture of pulmonary tissue occurs with the resultant escape of air into spaces in which air would not be present normally. The incidence of pneumothorax varies with gestational age, severity of pulmonary disease, need for assisted ventilation, mode of ventilation, and expertise of delivery room personnel. Following the initial rupture of a small airway or an alveolus, air may enter the perivascular and peribronchial spaces and track along the lymphatic channels. Air that dissects into the hilum results in a pneumomediastinum. Air that tracks into the pleural space manifests as a pneumothorax. Spontaneous rupture of the lung directly into the pleural space is thought to occur rarely but may be caused iatrogenically with the percutaneous insertion of a chest tube. Caution is required.

Pneumomediastinum frequently is an isolated disorder that occurs spontaneously in infants with minimal pulmonary disease. These infants usually are asymptomatic or minimally symptomatic because air in the mediastinum is capable of escaping to the tissues of the neck. Intrathoracic tension is relieved and circulation is not compromised. Infants with a pneumomediastinum should be observed. Intervention usually is unnecessary.

Pneumothorax may occur immediately in the delivery room or later when significant pulmonary disease has developed. The occurrence of a pneumothorax often is associated with positive pressure ventilation, but it also may occur in infants who are not receiving assisted ventilation. Following the initial air leak, the subsequent expansion of intrathoracic spaces often rapidly results in an increase of intrathoracic pressure such that there is an inability to ventilate the lungs and an inability to return venous blood to the heart. This is termed a “tension pneumothorax.”

The rapid clinical deterioration of such infants is caused by circulatory collapse and an inability to ventilate. Any infant who has a sudden precipitous change in ventilatory status associated with an abrupt fall in blood pressure should be evaluated immediately for a pneumothorax. Transillumination of the chest may be used for the rapid diagnosis of severe tension pneumothorax.

In cases where the clinical situation allows, an x-ray should be used to make or confirm the diagnosis. Infants in acute distress should have a needle aspiration performed to relieve the tension while preparation is made to place a chest tube. Symptomatic pneumothorax is managed with the insertion of a chest tube until the pulmonary leak is resolved. A chest tube may not be required if the pneumothorax is small and does not involve an infant who is not receiving positive pressure ventilation. Supplemental oxygen (FiO2 = 1 ) often is administered for 6-12 hours to hasten reabsorption of the trapped intrapleural air.