Evaluation of Neonatal Pneumothorax

B APILIOGULLARI 1 2 GS SUNAM 1 2 S CERAN 1 2 H KOC 0 2 0 Department of Paediatrics, Selcuk University, Meram Medical Faculty , Konya, Turkey 1 Department of Thoracic Surgery 2 Dr Burhan Apiliogullari Department of Thoracic Surgery, Selcuk University, Meram Medical Faculty , Beysehir Cad. 42090 Konya, Turkey - >> Version of Record - Dec 1, 2011 What is This? Downloaded from imr.sagepub.com by guest on October 16, 2014 Pneumothorax progresses quickly in newborns and can lead to death. This study collected data prospectively over a 2-year period on risk factors, clinical course and prognostic factors of newborn cases diagnosed and treated for pneumothorax. Thirty patients were evaluated for risk factors including concurrent disease, method and duration of chest drainage, oxygen saturation and mechanical ventilation. Pneumothorax developed mostly in male and mature infants during the first 48 h following birth; risk factors included concurrent respiratory distress syndrome and meconium aspiration. Mechanical ventilation was undertaken in 18 (60%) of the patients. Closed-tube drainage was used in 28 (93%) of the patients. Nine out of 10 patients (90%) whose oxygen saturation remained < 90% died. Thus, pneumothorax may develop during the neonatal period, especially in the presence of risk factors, and neonates with < 90% oxygen saturation, despite treatment, have a high mortality rate. Introduction Pneumothorax is more frequently observed in neonates (1 2%) than in older children (1.2 28 per 100 000),1 3 and the rate can increase to up to 30% in patients who have concurrent underlying lung disease or who require mechanical ventilation.1,2 The early diagnosis and treatment of neonatal pneumothorax (NP) is critical, as it may help to avoid complications and reduce mortality rates resulting from hypoxaemia, hypercapnia or impaired venous return.3 5 To date, there are few reports identifying the risk factors and prognostic factors of NP.6,7 The present study evaluated the clinical course of NP during treatment and identified putative risk and prognostic factors. Patients and methods STUDY POPULATION Prospectively collected data from newborn infants with pneumothorax observed and treated at the Neonatal Intensive Care Unit (NICU) and the Department of Thoracic Surgery in Selcuk University Hospital, Konya, Turkey, between January 2002 and July 2004 were included in this descriptive study. There were no exclusion criteria for the study. As this was a descriptive study, where data were obtained from patient records, no ethical approval was required for the study protocol. Verbal informed consent was obtained from the parents of all infants included in the study. Downloaded from imr.sagep2ub4.co3m 6by guest on October 16, 2014 STUDY ASSESSMENTS Patients were evaluated for the following: age at the time of enrolment in the study; sex, prematurity (term 37 weeks; preterm < 37 weeks); birth weight; method of delivery; sex; time of NP development ( 48 h, or > 48 h postdelivery); localization of NP (right, left or bilateral); degree of NP (the percentage of each pneumothorax was calculated as described by Light et al.8: 20% was considered mild; 21 40% was considered medium; > 40% was severe); the presence of one or more concurrent diseases (including respiratory distress syndrome [RDS], meconium aspiration syndrome, organ failure, asphyxiation and congenital deformities); history of mechanical ventilation; history of cardiopulmonary resuscitation immediately after delivery; episodes of thoracostomy and closed underwater drainage; effect of drainage on the partial pressure of oxygen in the blood (PaO2) and the saturation level of oxygen in haemoglobin (SaO2) (PaO2 50 mmHg and SaO2 90% were considered as successful); drainage period; and spontaneous resolution of NP. Mortality rate was also evaluated. For diagnosis of pneumothorax, baseline criteria included a clinical assessment, standard arterial blood gas analyses and chest X-rays. In cases where pneumothorax did not resolve spontaneously, patients were treated with a chest tube and closed underwater drainage using 8 14 F chest tubes or aspiration catheters through the fourth intercostal space and preaxillary line. In cases that were not mechanically ventilated, chest drains were clamped for 24 h and, in cases that were ventilated, the drains were clamped for 48 h before removal. Daily assessments of patients during their stay in the NICU included chest X-rays and arterial blood gas analyses. Results In total, 30 neonates with pneumothorax (age range 1 11 days) were included in the study. The patients baseline clinical characteristics are presented in Table 1. Pneumothorax was graded as medium or severe in 26 patients (87%). Coexisting disease was detected in 27 patients (90%); the types of diseases coexisting with NP are presented in Table 2. Nine of the 30 (30%) patients had a history of cardiopulmonary resuscitation immediately after delivery. Mechanical ventilation was performed in 18 patients (60%), including nine of the 10 fatal cases (90%). Sex Female 7 (23) Male 23 (77) Birth Term 25 (83) Preterm 5 (17) Birth weight, g 2000 23 (77) < 2000 7 (23) Method of delivery Vaginal 10 (33) Caesarean, elective/emergency 14/6 (47/20) Pneumothorax developed 48 h postdelivery 24 (80) > 48 h postdelivery 6 (20) Localization of pneumothorax Right 12 (40) Left 9 (30) Bilateral 9 (30) Degree of pneumothorax8 Mild 4 (13) Medium 14 (47) Severe 12 (40) Data presented as n (%) of patients. Downloaded from imr.sagep2ub4.co3m 7by guest on October 16, 2014 While tube thoracostomy and closed underwater drainage were performed in 28 patients (93%), NP resolved spontaneously in two cases. There was little difference in the number of cases with NP where the SaO2 was 90% after drainage (n = 13, 46%) compared with those where the SaO2 saturation was < 90% despite drainage (n = 15, 54%). PaO2 levels increased in 21 patients (75%) after chest tube insertion. In the majority of cases (n = 18, 64%), the air leak ceased in the first 12 24 h. The mean drainage period was 6.3 days (range 4 11 days). Ten of the 30 patients (33%) died (Table 3). Nine of the 10 fatalities occurred in patients with SaO2 < 90% despite drainage. Discussion Neonatal pneumothorax is a lifethreatening condition that is associated with high mortality and morbidity.3 Despite the high incidence, only 0.5% of cases of pneumothorax are symptomatic.1,9 It is known that NP occurs more often in young C C C C C C ;e Downloaded from imr.sagep2ub4.co3m 8by guest on October 16, 2014 males than in females.6,9,10 This was confirmed in the present study, where 23 (77%) of the patients were boys. NP is generally observed in the first 3 days of life.1,7 In agreement with the literature,1,7 in the present study, NP developed in the first 48 h in 24 cases (80%). Rates of the most common coexisting pathologies observed in the present study, i.e. RDS and meconium aspirat (...truncated)