Neonatal Air Leak SyndromesNeonatal Air Leak Syndromes

D R F A E Z A S O O B A D A RC O N S U L T A N T P A E D I A T R I C I A N A N D

N E O N A T O L O G I S TN E O N A T O L O G I S TA P O L L O - B R A M W E L L H O S P I T A L

Air Leaks

PneumothoraxPneumomediastinumPneumopericardiumpPneumoperitoneumSubcutaneous emphysemap yPulmonary Interstitial Emphysema (PIE)Air embolism

P/thorax

PIEAir embolism

Alveolarrupture

P/mediastinumSCE

P/pericardiumP/pericardiumP/peritoneum

Aetiology

Over-vigorous resuscitationIntubation/ IPPV/ NCPAP/ /‘Fighting’ ventilatorHigh PIP; Long I.Tg ; gMAS; RDS; Pneumonia; Pulmonary hypoplasia

Neonatal Pneumothorax

Incidence

1-1.5% of all newborns5Affects 5-14% of babies admitted to NICUsMales > FemalesTerms = Pre-termsSpontaneous pneumothorax : 10/15,000p p / 5,Bilateral in 10-21%Mortality 20%y

Clinical Presentation - 1

Signs of respiratory distress: grunting, ↑RR, recession, cyanosisApnoea, bradycardia, ↓BPDisplaced apex beatChange in breath sounds↑Ventilatory requirements

Clinical Presentation - 2

Sudden collapse with severe hypotension, p yp ,bradycardia, apnoea, hypoxia, respiratory acidosis

Investigations

CXR – AP, Lateral decubitus

Investigations

CXR – AP, Lateral decubitusTransillumination

Investigations

CXR – AP, Lateral decubitus,TransilluminationDirect needle aspiration – diagnostic & therapeuticp g p

Treatment - 1

Conservative therapy +/- 100% oxygenIf no underlying lung diseasey g gNo complicating therapyNo distressNo continuous air-leaks

Resolve in 24-48 hrs4 4

Treatment – 2Needle aspiration

Equipment21-23G butterfly needle3 yCleaning solutionGallipot/ sterile water orp /Syringe & 3-way tap

Treatment – 2Needle Aspiration

ProcedureClean skinInsert needle 2nd/3rd ICS MCLEnd of tubing under water & watch for bubbles orgApply continuous suction to syringe until rapid flow of air

Treatment – 3Thoracocentesis - Equipment

Chest drain 10 or 12FG mounted on trocharSterile gown/gloves & cleaning solutionLA, syringes & needlesSterile dressing pack – fine mosquito forceps, scalpel/blade large clampscalpel/blade, large clampUnderwater seal drain3-0/4-0 silk suture & transparent adhesive dressing3 0/4 0 silk suture & transparent adhesive dressing

Treatment – 3Thoracocentesis - procedure

Clean area & inject LAMake nick in skin along 4th/5th ICS MAL parallel to ibrib

Use fine mosquito forceps to make track for chest drain – just above rib belowdrain just above rib belowInsert chest drain through track about 2-3cm, having previously withdrawn trochar from tip of chest drain

Treatment – 4Thoracocentesis - procedureThoracocentesis procedure

Place clamp on chest drain proximal to tip of trochar & remove trochar completelyConnect chest drain to underwater seal drain with 10-20 cm H2O suction pressureR l d t h f i b bbli tRemove clamp and watch for air bubbling outSuture chest drain in placeC ith t t dh i d iCover with transparent adhesive dressingCXR

Removal of chest drain

Lung disease has improvedDrained no air for 24-48hrsPneumothorax resolved for 24-48 hrsNo longer requiring PIP >25Stop suction, clamp drain & remove on successive days CXRsdays – CXRsRemove during expiration if spontaneous breathing; inspiration if vent’dp

Complications

Profound ventilatory & circulatory compromise & deathIVHSIADH

Pneumomediastinum

D I A G N O S I S :D I S T A N T H E A R T S O U N D SS S O U S+ V E T R A N S I L L U M I N A T I O NC X R A P – S A I L S I G N

L A T E R A LT R E A T M E N T C O N S E R V A T I V ET R E A T M E N T - C O N S E R V A T I V E

Pneumopericardiump

C A R D I A C T A M P O N A D EC X R ; T R A N S I L L U M I N A T I O NR X : P E R I C A R D I A L T A P P I N GH I G H M O R T A L I T Y

Audit on Neonatal Air LeaksAudit on Neonatal Air Leaks

S S R N H N I C U3 1 . 0 7 . 2 0 0 1 - 3 1 . 0 7 . 2 0 0 7

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

3015

2 2

Rt p/thorax30

8

p/Lt p/thoraxBL p/thoraxP/mediastinum/P/pericardium

24

Birth Weight

25 24

22

20

15

Numbers

10 8

52

0<1 kg 1- <1.5 kg 1.5- <2.5 kg >=2.5 kg

Gestation & Mortality

30

20

25

30

20

28

10

15

20

8 44

9 TotalDied

Died0

5

Total<32 wks32-<37 wks

>=37 wks

Respiratory support prior to event

207

81 2

CMV/SIMVNone

18

NoneNCPAPHFOVH d til t dHand ventilatedUnspecified

Underlying diagnosis & Mortality

20

2522

15

20

10 8

11

TotalDied

55

43

1 1 1

4 43

01 1 1 1

2

Died

00

Air leaks on admission = 16

3

18RDS

2

11

8Pulm hypoplasiaMASTTNPneumoniaSpontaneous

Outcome of survivors

10

Normal devtDelayed devtN f ll

27

2 No follow-up

7

Summary & Recommendations

Multiple aetiology & not specific to NICUp gy pNot always caused by ventilationBeware post-surfactant effectp? MortalityVery low rate of CPyThe undiagnosed & untreated pneumothoraces –future approach

.Thank youy