A five-week-old, former 25-week gestational age infant required high pressure mechanical ventilatory support during the first several weeks of life. The baby is now clinically improved and weaning from mechanical ventilation.The attached CXR was obtained. The best next step in management is:

 

 

[center][/center]

 

 

 

 

[size=20px]A observation

 

B chest CT

 

C segmental resection

 

D lobectomy

 

E tube thoracostomy[/size]

Edited March 6, 20224 yr by Admin

B

A

A

correct answer

A observation

 

 

This baby has a pneumatocele (gas-filled cyst) as a result of barotrauma from mechanical ventilation. Other consequences of barotrauma in mechanically ventilated infants include pneumothorax, pneumomediastinum and pulmonary interstitial emphysema (PIE).

 

With the advent of surfactant therapy and gentle ventilation techniques, there has been a decline in the overall incidence of barotrauma in infants. Within the pediatric population, pneumatoceles are usually post-traumatic or post-infectious; typically implicated organisms include S. aureus, E. coli, Klebsiella, Enterobacter, Streptococcus and Pseudomonas. Pneumatoceles can occasionally be difficult to distinguish from congenital lung cysts and primary pulmonary blastoma (PPB) which should remain in the differential diagnosis.

 

Observational treatment will be successful in the majority of infant pneumatoceles. Chest CT would not add any useful information in an infant that is clinically stable. Tube thoracostomy should be avoided if possible as it may result in a bronchopleural fistula. Surgical resection should not be required in an asymptomatic or minimally symptomatic infant, given that the majority of pneumatoceles will resolve on their own, usually within months.

 

While less common than pneumatoceles associated with barotrauma alone, post-infectious pneumatoceles in mechanically ventilated infants have a higher mortality and morbidity rate due to complications of sepsis, their frequent multifocality and tendency to enlarge causing mass effect and/or rupture. Although thoracostomy tube drainage of air leaks should still be considered first line therapy, compressive atelectasis and tension physiology may require additional intervention. Anecdotal success with fibrin sealant via pigtail catheter and urgent bedside thoracotomy with lung resection or oversew of sites of air leak have been described in the emergency management of complications of barotrauma in mechanically ventilated infants.