Management of pneumothorax in hemodynamically stable preterm infants using high frequency oscillatory ventilation: report of five cases

Abstract

BackgroundDespite an increased use of non-invasive ventilatory strategies and gentle ventilation, pneumothorax remains a common complication in preterm infants. The ventilator management of infants with air leaks remains challenging in terms of both prevention and treatment. Recently the safety and efficacy of expectant management avoiding chest tube drainage to treat large air leak in preterm infants hemodynamically stable has been reported.Case presentationIn the present study, we report five cases of preterm infants with birth weight ≤ 1250 g affected by respiratory distress syndrome and treated with nasal continuous positive airway pressure as first intention. They were intubated for worsening of respiratory distress with increasing oxygen requirement and concomitant increase of respiratory rate and PCO2 values due to occurrence of pneumothorax, and they were successfully treated using high-frequency oscillatory ventilation without chest tube insertion.ConclusionIn our experience high-frequency oscillatory ventilation provided a conservative management of a significant pneumothorax in preterm newborns hemodynamically stable and requiring mechanical ventilation. This approach allowed us to avoid the increasing of air leak and the insertion of chest tube drainage and all the subsequent associated risks.

Effectiveness and safety of pneumothorax management in newborns without chest-tube insertion

“…The majority of infants were preterm (24 -77%), but only four (17%) of them had very low birth weight (less than 1500 g). Surfactant therapy was used in seven (23%) cases, and the median age at first dose of surfactant administration was 3.5 (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16) hours. In eight (26%) infants pneumothorax was diagnosed at the time of hospitalisation to the neonatal intensive care unit.…”

“…Increased risk of pneu-mothorax exists in infants with respiratory distress syndrome (RDS), meconium aspiration syndrome (MAS), pulmonary hypoplasia, and in those who require resuscitation and/or respiratory support after birth [5]. This complication is associated with increased morbidity and a higher risk of death, and it occurs despite the use of surfactant and modern ventilation regimens [6]. Pneumothorax occurrence can lead to increased respiratory distress, hypoxaemia, hypercapnia, hypotension, lung collapse, etc.…”

“…An effective alternative for such a newborn with pneumothorax on mechanical ventilation (MV) could be expectant conservative management that prevents the development of complications associated with chest-tube insertion [1,5]. One of the options of such management is the use of high-frequency oscillatory ventilation (HFOV), which can ensure a successful result with this approach [6].…”

“…Several recent reports described conservative management for neonates with symptomatic pneumothorax, who were on non-invasive respiratory support or mechanical ventilation [1,5,6]. Infants with stable respiratory distress, cardiovascular status, and blood gases on relatively low ventilatory settings may not need chest-tube insertion [5].…”

Use of high frequency oscillatory ventilator in neonates with respiratory failure: the clinical practice in Taiwan and early multimodal outcome prediction

“…A total of 8.7% patients who received HFOV had persistent air leakage. Although HFOV is not a standard treatment for neonates with air leak, it can have beneficial effects on the prevention of recurrent pneumothorax and reverse severe hypercapnia 36,37 . For low birth weight infants, the lower mean frequency of our preterm infants www.nature.com/scientificreports www.nature.com/scientificreports/ under HFOV (12~13) is due to the ventilator machine, with Babylog 8000 (Dräger, Lübeck, Germany) switched from conventional mode to HFOV mode.…”