Chapter 63

1. Problem. An infant may have a pneumothorax (an accumulation of air in the pleural space). An infant can develop a pneumothorax spontaneously or due to ventilator associated barotrauma.

2. Immediate questions

1. Are symptoms of tension pneumothorax present? Tension pneumothorax presents as a medical emergency, and the patient's status will deteriorate acutely. The following signs and symptoms may be seen with tension pneumothorax: cyanosis, hypoxia, tachypnea, a sudden decrease in heart rate with bradycardia, a sudden increase in systolic blood pressure followed by narrowing pulse pressure and hypotension, an asymmetric chest (bulging on the affected side), distention of the abdomen (secondary to downward displacement of the diaphragm), decreased breath sounds on the affected side, and shift of the cardiac apical impulse (most consistent finding) away from the affected side. A cyanotic upper half of the body with a pale lower half can be seen.

1. Is the patient asymptomatic? A spontaneous pneumothorax occurs in 0.7% of newborns. An asymptomatic pneumothorax is present in 1–2% of neonates. Most of these cases are discovered on chest radiograph at admission. Up to 15% of these infants were meconium stained at birth.

1. Is mechanical ventilation being used? The incidence of pneumothorax in patients receiving positive-pressure ventilation is 15–30%. A life-threatening tension pneumothorax may result from mechanical ventilation.

3. Differential diagnosis. The incidence is higher in those with respiratory distress syndrome (up to 40%). The rates of pneumothorax are declining due to the use of surfactant and improved ventilator management.

1. Pneumothorax

1. Symptomatic pneumothorax (includes tension pneumothorax).

1. Asymptomatic pneumothorax.

1. Persistent pneumothorax.

1. Pneumomediastinum. Air in the mediastinal space that may be confused with a true pneumothorax.

1. Congenital lobar emphysema. Overdistention of one lobe secondary to air trapping occurs most commonly (47%) in the left upper lobe. Other lobe involvement is right upper lobe (20%), right middle lobe (28%), and lower lobes (rare). The causes of congenital lobar emphysema are probably multifactorial.

1. Atelectasis with compensatory hyperinflation. Compensatory hyperinflation may appear as a pneumothorax on a chest radiograph.

1. Pneumopericardium. In neonates, pneumopericardium and tension pneumothorax can both present as sudden and rapid clinical deterioration. In pneumopericardium, the blood pressure drops, heart sounds are distant or absent, and pulses are muffled or absent. Massive abdominal distention can also be seen. In tension pneumothorax, the blood pressure may initially increase, but then hypotension follows. The chest radiograph easily differentiates the two. A pneumopericardium has a halo of air around the heart (see Figure 10–17). The more common event is a tension pneumothorax. If one is unsure and time does not permit radiographic verification, it is better to insert a needle in the chest on the suspected side. If no response, then a needle should be inserted on the other side. If there is still no response, then the diagnosis of pneumopericardium should be considered.

1. Congenital cystic adenomatoid malformation. This rare abnormality results from abnormal embryogenesis. An overgrowth of bronchioles occurs with a decrease in alveolar growth. The infants present with respiratory distress ranging from minor to severe. Tachypnea and cyanosis can ...

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