Systemic Air Leak Syndrome in a Sick Full-Term Infant

Abstract

A 3.3-kilogram, full-term baby girl was transferred from a local hospital at 48 hours of age because of respiratory failure due to meconium aspiration syndrome. The baby was delivered by emergency caesarian section because of fetal distress associated with thick meconium liquor. The mother was 30 years old, gravida 4, para 3, with 3 living healthy siblings. Antenatal history was unremarkable. At birth, the infant required endotracheal suctioning of thick meconium three times followed by intubation and mechanical ventilation due to respiratory distress. The Apgar score was 3 and 6 at the first and fifth minute. At 48 hours of age, the infant developed bilateral pneumothorax that required chest tube insertion in each side. The mechanical ventilation settings before transferring the infant were as follow: positive inspiratory pressure (PIP): 45 mm H2O, positive end-expiratory pressure (PEEP): 3 mm H2O, respiratory rate: 70 breaths per minute, inspiratory to expiratory time ratio was 0.9:1, and supplemental oxygen (FIO2= 1.0). The oxygen concentration (SO2) was 88% using the pulse oximeter. Arterial blood gas was: pH 7.12, PO2 48 mm Hg, PCO2 72 mm Hg, HCO2 18 mm Hg, and base deficit was -8. Thirty minutes after arrival at our neonatal intensive care, the infant developed severe surgical emphysema involving the whole body and associated with a sudden onset of severe abdominal distention. An urgent chest and abdominal x-ray ( Figure) demonstrated multiple subcutaneous emphysema affecting the face, scalp, chest wall, interstitial emphysema, pneumoperitoneum, pneumothorax, and pneumomediastinum. Bilateral chest tubes were reinserted. Abdomenocentesis followed by insertion of a penrose abdominal drainage were necessary to control the progressive pneumoperitonium. The infant required high frequency mechanical oscillatory ventilation (SensoriMedics 3100 A) for 12 days supported by nitric oxide inhalation for 2 days to treat the hypoxic respiratory failure before being extubated. Although the overall explanation for the development of pneumoperitnium was systemic air leak, a gastrointestinal contrast follow through study was done on the third day, which ruled out gut perforation. Feeding was commenced successfully after extubation. The infant was discharged at 4 weeks of age, at which time he was breathing spontaneously on room air. Outpatient clinic follow-ups were satisfactory.