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)
- 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).
- No strict contraindications
- Angiocath or butterfly needle (for neonates)
- Large syringe (>20mL)
- 3-way stop-cock (to keep system closed)
- 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.
- 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.