A 2-day-old girl is in the neonatal intensive care unit due to prematurity and respiratory distress. The patient was born at 29 weeks gestation via spontaneous vaginal delivery to a 28-year-old primigravida mother. Her mother received a single dose of antenatal betamethasone before undergoing a precipitous delivery. Birth weight was 1.3 kg (2 lb 14 oz), and Apgar scores were 5 and 8 at 1 and 5 minutes, respectively. The patient received surfactant replacement and was placed on nasal continuous positive airway pressure (nCPAP) and has been receiving intravenous fluids. A few minutes ago, she developed an acute onset of grunting and increased work of breathing. Respiratory rate is 70/min and pulse oximetry is 80%. Lung examination shows decreased breath sounds on the left and intercostal retractions. Cardiac examination reveals heart sounds that are loudest over the right side of the chest and no murmurs. Bedside transillumination is performed, and the left chest shows increased brightness relative to the right. Which of the following is the best next step in management of this patient?

Question

A 2-day-old girl is in the neonatal intensive care unit due to prematurity and respiratory distress.  The patient was born at 29 weeks gestation via spontaneous vaginal delivery to a 28-year-old primigravida mother.  Her mother received a single dose of antenatal betamethasone before undergoing a precipitous delivery.  Birth weight was 1.3 kg (2 lb 14 oz), and Apgar scores were 5 and 8 at 1 and 5 minutes, respectively.  The patient received surfactant replacement and was placed on nasal continuous positive airway pressure (nCPAP) and has been receiving intravenous fluids.  A few minutes ago, she developed an acute onset of grunting and increased work of breathing.  Respiratory rate is 70/min and pulse oximetry is 80%.  Lung examination shows decreased breath sounds on the left and intercostal retractions.  Cardiac examination reveals heart sounds that are loudest over the right side of the chest and no murmurs.  Bedside transillumination is performed, and the left chest shows increased brightness relative to the right.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d722_9f66_bc81_ffd1a352cd10_MD0003_00 This patient's presentation-respiratory distress, unilaterally decreased breath sounds with increased brightness on transillumination-is consistent with pneumothorax. Premature infants, particularly those with respiratory distress syndrome (RDS), are at particularly increased risk because insufficient surfactant makes the alveoli less expandable and more prone to rupture. Mechanical ventilation (eg, nasal continuous positive airway pressure [nCPAP] in a neonate) also increases pneumothorax risk by increasing transpulmonary pressure. In addition, meconium aspiration syndrome (most common in postmature neonates) is associated with pneumothorax because meconium plugging of airways traps distal gas, promoting alveolar overdistension and rupture. Typical presentation includes acute-onset tachypnea, grunting, cyanosis, and decreased breath sounds on the affected side. Patients with a tension pneumothorax, in which high intrapleural pressure decreases venous return and subsequent cardiac output, exhibit severe distress with hypotension and hypoxemia. Accumulation of intrapleural air may cause displacement of the heart to the right, as in this case. Increased brightness over the affected hemithorax on transillumination of the chest is supportive of the diagnosis. Chest radiograph may be performed in hemodynamically stable patients or if the diagnosis remains unclear after transillumination (Choice E). This patient with hypoxia, severe respiratory distress, mediastinal deviation, and unilateral positive transillumination likely has a life-threatening tension pneumothorax, and emergency needle thoracostomy is required to evacuate the intrapleural air. (Choice A) Although positive airway pressure is associated with increased risk of pneumothorax, this premature infant has surfactant deficiency and requires respiratory support. Therefore, reducing mean airway pressure should be considered, but discontinuing nCPAP altogether will worsen atelectasis and distress. This patient's pneumothorax is causing hemodynamic instability and must be evacuated first. (Choice B) Positive end-expiratory pressure (PEEP) prevents collapse of alveoli upon expiration and can contribute to alveolar distension. Increasing PEEP in a patient with tension pneumothorax would likely increase intrapleural air and should be avoided. (Choice C) Chest physiotherapy can be helpful in treating atelectasis due to RDS or meconium plugging. In contrast to pneumothorax, atelectasis does not transilluminate. (Choice D) Echocardiogram is used to evaluate for congenital heart disease, which can present with hypoxia and respiratory distress. However, this patient's unilaterally decreased breath sounds, lack of murmur, and transillumination findings make pneumothorax more likely. Educational objective: The risk of pneumothorax is increased in premature neonates, particularly those with respiratory distress syndrome who are receiving mechanical ventilation. Transillumination reveals increased brightness on the affected side. Hemodynamic instability or signs of tension pneumothorax (eg, mediastinal shift) warrant emergency needle thoracostomy. References: Neonatal pneumothorax: a descriptive regional Danish study. (http://www.ncbi.nlm.nih.gov/pubmed/28013308) Needle aspiration versus intercostal tube drainage for pneumothorax in the newborn. (http://www.ncbi.nlm.nih.gov/pubmed/30707441)

A 2-Day-Old Girl Is in the Neonatal Intensive Care Unit