Positional treatment without mechanical ventilation in a very preterm infant with unilateral pulmonary interstitial emphysema: case report and review of the literature

Abstract

Background Pulmonary interstitial emphysema (PIE) in very low birth weight infants is a rare but severe complication. Although most of these air leaks develop in mechanically ventilated infants, they have also been reported in infants exposed only to nasal continuous positive airway pressure (CPAP). The optimal treatment for PIE is still under discussion and includes different approaches such as unilateral intubation, high frequency oscillation ventilation and even surgical lobectomy. However, as yet, there has been no report on complete resolution of unilateral PIE by positioning therapy without mechanical ventilation. Case presentation We report the case of a 28 +1 gestational week twin, 990 g birth weight, Apgar 9–10-10. After stabilization with nasal CPAP the baby received surfactant by less invasive surfactant application (LISA) technique in the delivery room after 35 min of life, and continued respiratory support with nasal CPAP. At day 5 X-ray presented unilateral PIE, while pCO 2 increased from 40 mmHg to 55 mmHg and FiO 2 from 0.21 to 0.28 to achieve SpO 2 in the target range of 89–94%. The baby was treated by strict positioning on the affected hemithorax in a special splint while spontaneously breathing on High Flow Nasal Cannula (HFNC). Complete resolution of the unilateral PIE was observed after 96 h. No chronic lung disease developed. Conclusion For unilateral PIE in very preterm infants, positioning on the affected hemithorax without mechanical ventilation is a therapeutic option.

Unilateral neonatal pulmonary interstitial emphysema managed conservatively: A case report

“…We noticed significant clinical and radiographical improvement within 4 days. This rapid improvement in PIE was similar to what has been previously reported when positional therapy was successfully used in its management 15 …”

“…higher odds of developing a pneumothorax, and no significant difference was detected when using various nCPAP levels (+5 to 8 cmH2O). 26 Several management approaches of unilateral PIE have been reported from decubitus positioning, [13][14][15] conservative management, 27 corticosteroid therapy, 28 selective unilateral bronchial intubation, 16,29 ipsilateral bronchial occlusion, 30 high-frequency jet ventilation, 8 pulmocentesis, 17 and surgical intervention. 18,19 The choice of the specific treatment modality is based on the size of the lesion, degree of lung involvement, clinical stability, prior treatment modalities used, and institutional preference.…”

“…This rapid improvement in PIE was similar to what has been previously reported when positional therapy was successfully used in its management. 15 In neonatal unilateral lung disease, ventilation is enhanced when the healthy lung is placed in a nondependent position, contrary to adults with unilateral lung disease. This positioning results in the uppermost lung units operating on the steep portion of the pressure-volume loop and the lowermost lung units on the flat portion of the pressure-volume loop, which results in the uppermost lung units being better ventilated due to the higher compliance.…”

“…1 PIE can also be subdivided into localized, diffuse, unilateral, or bilateral types. 1 Several management approaches of unilateral PIE have been reported from conservative management, [13][14][15] selective intubation, 16 to surgical intervention. [17][18][19] PIE has high mortality rates in preterm infants ranging from 24% to 67%.…”

Manejo de enfisema intersticial unilateral adquirido en un recién nacido prematuro mediante intubación bronquial selectiva: descripción de un caso y revisión de la literatura

“…El manejo terapéutico del enfisema bulloso es difícil y no siempre exitoso. Dentro de las opciones están posicionamiento del neonato sobre el lado afectado, disminuir presiones inspiratorias máximas, disminuir frecuencia respiratoria y acortar el tiempo inspiratorio 7,8 . Otras medidas terapéuticas incluyen el uso de ventilación de alta frecuencia, administración de corticoides, resección quirúrgica de la porción más afectada e intubación selectiva del pulmón contralateral 5 .…”