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The occurrence and clinical implications of pneumothorax in preterm infants with hyaline membrane disease (HMD), particularly those receiving continuous distending pressure (CDP) or intermittent positive pressure ventilation (IPPV. The document emphasizes the importance of prompt diagnosis and treatment to prevent persistence or recurrence of pneumothorax and improve outcomes.
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Archives of Disease in Childhood, 1975, 50, 449.
respiratory distress, and^ particularly in^ the^ presence
the newborn period in which prompt treatment can be life saving. Detection in newborn infants depends as much on a high degree of awareness of
experience of this condition over the last 2A years and emphasize the increasing importance of its
Received 11 November 1974. *Present address: Department of Paediatrics, Addenbrooke's Hospital, Cambridge.
occurrence in low birthweight infants with HMD
(IPPV) and continuous distending pressure (CDP). Pneumomediastinum and^ pneumopericardium are included in the (^) analysis as (^) they are (^) probably a variant of the same underlying pathology.
mediastinum was^ studied^ in^34 newborn infants.^ These
and allied conditions (^) occurring in the (^) special care
incomplete. 3 infants^ were^ referred^ from^ other^ hospitals
Yu, Liew, and Roberton
The overall incidence of pneumothoraces and (^) allied conditions was 3/1000 live births. This study includes 26 infants with pneumothoraces all of whom were symptomatic and in whom deterioration in respiratory symptoms had led to chest x-ray. 6 out of the 26 had coexisting pneumomediastinum (23%) and one had coexisting pneumopericardium. 6 other infants had isolated pneumomediastinum and 2 had severe pul- monary interstitial emphysema with lung cysts; these 8 were asymptomatic and were diagnosed on routine x-rays. Males were more than twice as common as females (24: 10). Pneumothoraces were found nearly twice as frequently on the right as on the left (R:L = 14:8) and 4 patients (15%) had bilateral pneumothoraces. The (^) infants studied can be separated into two distinct groups depending on whether there (^) was associated idiopathic respiratory distress syndrome-presumably HMD (Table I). The first group, that (^) of infants
Infants' without HMD Infants with HMD
No. 11 23 Gestation (w) 40 (38-41) 34 (27-38) Birthweight (g) 3453 (2710-4130) 2307 (990-3510) Age of onset (h) Birih 45 (12-140) (2 at 14 h) Apgar score at birth 4 or less 4 7 Endotracheal intubation and IPPV at birth 4 8 Aspiration of meconium or blood 6 0 CDP or IPPV at onset of (^) pneumothorax - (^16)
HMD, hyaline membrane disease; CDP, continuous (^) distending pressure; IPPV, intermittent positive pressure ventilation.
common: (^) they were (^) usually diagnosed in the first (^) hour of life, being mainly term or post-term infants presenting
zealous resuscitation, and evidence of aspiration of meconium, blood, or^ mucus. This group of 11 infants accounted for only 32% of pneumothoraces in Oxford. Their mean gestational age was 40 weeks (range 38 to (^41) w) and mean birthweight 3453 g (range 2710-4130 g). In 9 infants the signs were evident at delivery, while (^) in the remaining 2 pneumothorax was not obvious until 14 and 15 hours of age, respectively. There was a strong possibility of aspiration of meconium or blood as a predisposing event^ in^6 out of the 11 infants and the possible aspiration ofmucus could not be ruled out in (^) any infant. 4 ofthe pneumothoraces occurred in resuscitated infants, but it is not possible to ascertain to what extent overzealous resuscitative efforts or the underlying cause
3 infants in this group had coexisting pneumomediasti- num. In the second group, pneumothorax and pneumo- mediastinum occurred as a complication of HMD in 23 infants, and these accounted for 68% of the infants in this series. The types of air leak developing in the 23
Infants without Infants with HMD (11) HMD (23)
Pneumothorax alone 7 12 Pneumothorax with pneumomediastinum 3 3 Pneumothorax with pneumopericardium 0 1 Pneumomediastinum alone 1 5 Severe pulmonary interstital emphysema 0 2 with lung cysts
age was 34 weeks (range 27-38 w) and mean birthweight was 2307 g (range 990-3510 g). All suffered from respi- ratory distress syndrome presumably due^ to^ HMD. Initial x-rays were (^) compatible with HMD and did not show (^) pneumothoraces. Onset of (^) pneumothorax was later than in the first group and occurred at a mean of 45 hours (^) postnatally (range 12 to (^140) h). The (^) diagnosis was strongly suspected in all 16 infants with (^) pneumo- thorax in this group before x-ray confirmation. 4 infants presented with acute collapse and 12 with un- explained but more gradual clinical deterioration during the course of the respiratory distress syndrome so that repeat chest x-rays were taken to detect possible pneu- mothorax. The remaining 7 infants, 5 of whom had pneumomediastinum without pneumothorax and 2 with severe pulmonary interstitial emphysema and lung cysts were^ detected^ by routine^ chest^ x-ray without antecedent clincial (^) suspicion. 12 of the 16 infants with pneumothorax were on either CDP (8 cases, mean duration 30 h, range 2-70 h) or IPPV (4 (^) cases, mean duration 23 h, range 2-120 h) at the time of onset of pneumothorax. All infants received a maximum CDP of 10 cm H20 except one early case in whom 15 cm H was (^) applied for a (^) period of 9 hours. The 4 infants (^) who developed pneumothorax (^) during IPPV were (^) being ventilated at a pressure of 40 cm H20. Only one infant was subjected to IPPV in association with positive end-expiratory pressure and this was discontinued 20 hours before the onset of (^) pneumothorax. The overall incidence of pneumothorax and allied conditions occurring in infants with HMD was 11% (23 out of 216). 15% of infants with HMD on CDP or IPPV developed these (^) complications (16 out of 106). This increased incidence was most evident in infants who had (^) received CDP alone and was lqwer in infants on IPPV (Table III).
Yu, Liew, and Roberton
to be 0 05-0 (^) 07% (Harris and Steinberg, 1954;
they are^ probably related (Ovenfors, 1964; Cald- well, Powell, and^ Mullooly, 1970; Thibeault et al., 1973). In this series, a (^0 3) % incidence of pneumo-
birthweight infants with HMD accounted for 68%
recently it^ has^ been^ recognized that HMD^ signifi-
become even more frequent (Lancet, 1973; Baum
unexpected deterioration at any time during CDP
sufficient. A horizontal beam, lateral ('cross- table') view of the chest with the patient in the supine position should always be done (Roberton,
pleural air collecting at the top of the thoracic
without HMD who had only moderately severe
found it useful to replace a new drain through the
Overall mortality rate for pneumothorax in this series was 0 04 % (5 in 11 169 live births). The
without HMD was uniformly good and all the
Mortality rate^ in^ the infants with HMD developing
statistically significant (^) (X2 =^ 3X15, P > 0 05) and
higher inflation pressures with IPPV are necessary.
thorax, when promptly and (^) adequately treated, may
452
Pneumothorax in^ the newborn^453
help in the preparation of the manuscript.
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Kirschner, P.^ A., and Strauss, L. (1964).^ Pulmonary^ interstitial emphysema in the newborn infant, precursors and sequelae. A clinical and pathologic study. Diseases of the Chest, 46, 417. Lancet (1973). Increasing the transpulmonary pressure in respira- tory-distress syndrome, 2, 244. Malan, A. F., and de V. Heese, H. (1966). Spontaneous pneumo- thorax in the newborn. Acta Paediatrica Scandinavica, 55,224. Mathias, (^) J. (1966). Resuscitation of the newborn. Lancet, 1, 262. Northfield, T. C. (1971). Oxygen therapy for spontaneous pneumo- thorax. British Medical J7ournal, 4, 86. Ovenfors, C. 0. (1964). Pulmonary interstitial emphysema: an experimental roentgen-diagnostic study. Acta Radiologica, 244, 1. Peterson, H. G., and Pendleton, M. E.^ (1955). Contrasting^ ro- entgenographic pulmonary patterns of the^ hyaline^ membrane and fetal aspiration syndrome. American^ journal of^ Roentgen- ology, 74, 800. Roberton, N. R. C. (1975). Recent Advances in Respiratory Diseases. Ed. by T. H. Stretton. Churchill, London. (In the press.) Solis-Cohen, L., and^ Bruck,^ S.^ (1934).^ A^ roentgen^ examination of the chest of 500 newborn infants for pathology other than enlarged thymus. Radiology, 23, 173. Steele, R. W., Metz, J. R., Bass, J. W., and Du Bois, J. J. (1971). Pneumothorax and pneumomediastinum in the newborn. Radiology, 98, 629. Thiebeault, D. W., Lachman, R. S., Laul, V. R., and Kwong, M. S. (1973). Pulmonary interstitial emphysema, pneumo- mediastinum, and pneumothorax. American journal of Diseases of Children, 126, 611.