Pulmonary Air Leaks

Pulmonary air leaks are a common occurrence in the neonatal intensive care unit. The air may present as pneumothorax, pulmonary interstitial emphysema, pneumomediastinum, pneumopericardium, or pneumoperitoneum.

CLINICAL FEATURES Spontaneous pneumothorax can occur in term and postterm infants following intrapartum asphyxia and meconium aspiration. Currently, however, pneumothorax has increased in incidence with the use of continuous positive airway pressure, positive end-expiratory pressure, mechanical ventilation, and cardiopulmonary resuscitation. Uneven ventilation caused by aspirated blood, mucus, meconium, and amniotic fluid debris can also result in an air leak. Atelectasis, poor ventilation, and air trapping are common predisposing factors. Premature, low-birth-weight infants with surfactant deficiency have a high incidence of air leaks (30 percent), as do newborns with meconium aspiration syndrome (10 percent).

The signs and symptoms of an air leak are those of respiratory distress and often present as an acute clinical deterioration. Grunting respirations and intercostal, sternal, and subcostal retractions may be seen. Cyanosis, elevated respiratory rate, and elevated heart rate are common. Auscultation of the chest reveals decreased breath sounds on the affected side of a pneumothorax, distant heart sounds, and a shift of the mediastinum. Transillumination of the chest with a high-intensity lamp may aid in the diagnosis. A chest x-ray is diagnostic. The accuracy can be improved with a cross-table lateral film of the chest taken along with the anteroposterior and lateral views.

TREATMENT An asymptomatic pneumothorax that is less than 20 percent of the volume of the affected side may be followed clinically with no therapy and with serial radiographic studies every 4 h. Any pneumothorax with severe respiratory distress and clinical deterioration needs emergency treatment. When there are mediastinal shift and cardiovascular collapse, rapid decompression at the fourth intercostal space with a 21-gauge needle attached to a three-way stopcock and a large syringe can be lifesaving.

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