Transillumination for and Aspiration of Pneumothorax in Neonates

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We mentioned in last week’s Morsel that for neonates not responding to resuscitative efforts, that you can transilluminate the chest to determine if there is a pneumothorax present. Let’s finish that discussion:

Neonates are prone to developing a pneumothorax.

  • Lack of surfactant makes premature lungs stiff and fragile.
    • The child who requires bagged respirations is at risk of having iatrogenic ptx (why we need to pay attention to the pressure that we are using)
  • The resuscitative efforts can be thwarted by an undiagnosed pneumothorax
    • The very compliant chest wall allows for increased intrathoracic pressures to be more directly related to the right atrium and, thus, leading to decreased Preload and cardiac output.
    • In addition, neonates will become bradycardic merely from hypoxia.

Certainly the preferred diagnostic test would be a Chest X-Ray, but… there often isn’t time.

  • In a pinch, you can use Tranillumination of the chest to help with your diagnosis
    • Place light source (otoscope, transilluminator) on infant’s chest. Ensure it isn’t hot.
    • A normal chest will have a small glowing “Halo” around the light source. Usually it extends less than 1 cm from the light source and is symmetric.
    • If the chest “lights up like a jack-o-lantern or ET’s chest” (large area of redness that is often asymmetric), then ptx should be HIGH on your DDx list.
    • You should compare to the other side if you are unsure.

So, you’ve just diagnosed a pneumothorax in a neonate, now what do you do? ANSWER = Aspirate

  • Aspiration of pneumothorax (Click here to see video)
    • Indication
      • Traditionally used to relieve tension pneumothorax.
      • In small children and neonates, may be the definitive procedure for simple pneumothorax.
      • More compliant chest wall and elastic tissues in kids may allow for the hole to spontaneously seal after the procedure so that you don’t have to follow it up with a traditional chest tube.
      • If the ptx re-accumulates after aspiration, then a thoracostomy tube will need to be placed (but give the kid a chance first).
    • Contraindication
      • No strict contraindications
    • Equipment
      • Angiocath or butterfly needle (for neonates)
      • Large syringe (>20mL)
      • 3-way stop-cock (to keep system closed)
    • Procedure
      • Locate 2nd or 3rd intercostal space at the midclavicular line
      • Prep skin with antiseptic and provide analgesic/anesthetic.
      • Advance needle perpendicularly over superior border of rib while aspirating. Having saline in syringe will allow you to detect when you’ve entered the ptx.
      • When bubbles are present or you have free movement of the syringe plunger, evacuate the pneumothorax.
      • A 3-way stopcock can be placed between syringe and butterfly needle, which will allow for controlled evacuation of pneumothorax.
    • Complications
      • Injury to neurovascular bundle
      • Injury to thoracic organs

 

Baldwin, S. and T.E. Terndrup, Thoracostomy and Related Procedures, in Textbook of Pediatric Emergency Procedures, 2nd Edition, C. King and F.M. Henretig, Editors. 2008, Lippincott Williams & Wilkins. p. 355-390.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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