Expectant Management of Pneumothorax in Ventilated Neonates Ita Litmanovitz and Waldemar A.

Carlo Pediatrics 2008;122;e975; originally published online October 13, 2008; DOI: 10.1542/peds.2008-1269

The online version of this article, along with updated information and services, is located on the World Wide Web at:
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2008 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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ARTICLE

Expectant Management of Pneumothorax in Ventilated Neonates

Ita Litmanovitz, MDa,b, Waldemar A. Carlo, MDc
aNeonatal Department, Meir Medical Center, Kfar Saba, Israel; bSackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; cDepartment of Pediatrics, University of Alabama, Birmingham, Alabama

The authors have indicated they have no nancial relationships relevant to this article to disclose.

Whats Known on This Subject

The current practice is to place a thoracostomy tube in infants who have a pneumothorax and require a ventilator. It is not known whether expectant treatment can be a possibility for these infants.

What This Study Adds

This study shows that a substantial proportion of infants who have a pneumothorax while on a ventilator can be treated expectantly without thoracostomy tube placement.

ABSTRACT
OBJECTIVE. The purpose of this study was to assess the incidence and outcome of managing a pneumothorax without tube thoracostomy and to determine the clinical and laboratory characteristics that distinguish infants with a pneumothorax who can be treated without chest-tube insertion. METHODS. A retrospective study was performed of neonates who were admitted to the

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Key Words chest tube, newborn infant, articial respiration
Accepted for publication Jul 29, 2008 Address correspondence to Waldemar A. Carlo, MD, University of Alabama, Division of Neonatology, 619 S 20th St, 525 NHB, Birmingham, AL 35233. E-mail: wcarlo@peds. uab.edu

neonatal intensive care unit at the University at Alabama at Birmingham from 1992 to 2005 and had a pneumothorax while on mechanical ventilation. Infant characteristics, respiratory and radiologic diagnoses, and respiratory management data (ventilator settings and blood gases) were compared between infants who initially were treated with a chest tube versus those initially treated without a chest tube.
RESULTS. A total of 136 ventilated infants with pneumothorax while on a ventilator

were included in the nal analysis; 101 (74%) were treated initially with a chest tube PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 2008 by the and 35 (26%) without a chest tube. Of those who did not receive a chest tube American Academy of Pediatrics initially, 14 were treated with needle aspiration and 21 with expectant treatment. Infants who were treated initially without a chest tube were on a lower ventilator settings (mean airway pressure and fraction of inspired oxygen) and had better blood gases (arterial oxygen saturation, PCO2, and pH) compared with infants who were treated with a chest tube. Infants who were treated initially with needle aspiration were more likely to require subsequent chest-tube insertion than infants who had expectant treatment (43% vs 10%).
CONCLUSIONS. It is possible to treat expectantly without initial chest-tube placement a select group of ventilated neonates with pneumothorax. Pediatrics 2008;122:e975e979

NEUMOTHORAX IS MORE frequent in the neonatal period than at any other time in life. Symptomatic pneumothorax occurs in 0.08% of all live births1 and in 5% to 7% of infants with birth weight of 1500 g.2,3 The risk for pneumothorax is increased in infants with respiratory distress syndrome, meconium aspiration syndrome, and pulmonary hypoplasia and in infants who need resuscitation at birth.4,5 Continuous positive airway pressure and positive pressure ventilation further increase the incidence of pneumothorax.4,5 Surfactant,6,7 the use of synchronized8 or volume ventilation,9 and high-rate, low-tidal-volume ventilation8 decrease the incidence of pneumothorax. There is general agreement that for infants with an asymptomatic pneumothorax without underlying pulmonary disease, specic treatment is not necessary.1013 Whereas needle aspiration may be used for infants with mild symptoms, it is well accepted that insertion of an intrapleural catheter (chest tube) is required for ventilated infants1014; however, tube thoracostomy may result in important morbidities. Lung injury,1517 phrenic nerve paralysis,1820 chylothorax,21 and hemorrhagic pericardial effusion22 have been reported as complications of chest-tube placement in neonates. Furthermore, pulmonary penetration of the chest tube into the pulmonary parenchyma is a complication that is underdiagnosed by chest radiographs.15,23 A study of autopsies of 28 infants with pneumothorax reported a lung perforation rate of 25%.17 Pain and discomfort as a result of insertion, presence, or removal of the chest tube are also reported commonly in adults.24,25 Two recent reports described a more conservative treatment for neonates with a symptomatic pneumothorax, but most of the infants were not receiving mechanical ventilation.1,26 We have had experience with expectant treatment of critically ill ventilated infants with pneumothorax for more than a decade. The purpose of this study was to assess

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14 614 infants admitted to NICU 19922005

307 infants with a pneumothorax (2.1%)

125 term infants

182 preterm infants

6 medical charts lost 2 urgent chest-tube insertions during resuscitation 17 chest-tubes inserted before transport to UAB 2 multiple anomalies 79 not on mechanical ventilation

8 medical charts lost 35 urgent chest-tube insertions during resuscitation 8 chest-tubes inserted before transport to UAB 14 not on mechanical ventilation

19 term infants with pneumothorax on mechanical ventilation

117 preterm infants with pneumothorax on mechanical ventilation

7 without chest tube

12 with chest tube

28 without chest tube

89 with chest tube

6 expectant management

1 needle aspiration

15 expectant management

13 needle aspiration

FIGURE 1 Flowchart of study infants. UAB indicates University of Alabama at Birmingham; CT, computed tomography.

the incidence and rate of success of managing pneumothorax without tube thoracostomy and to determine the clinical and laboratory characteristics that distinguish infants who have a pneumothorax and can be treated without chest-tube insertion from those who cannot. METHODS A retrospective study of neonates who were admitted to the NICU at the University of Alabama at Birmingham from January 1992 to December 2005 was conducted. During the study period, between 6 and 12 neonatologists were responsible for patient care in this level III, referral NICU. Treatment decisions regarding the pneumothorax were made by the clinical team under the direction of an attending neonatologist. Our clinical consensus is that a chest tube is not always indicated for patients with a pneumothorax, even for those on a ventilator. Infants with acceptable respiratory distress, cardiovascular examination, and blood gases on relatively low ventilatory settings may not need chest-tube insertion. The study was approved by the institutional review board. Infants with pneumothorax were identied using a research NICU database. All data in the NICU database were collected immediately after discharge of the infant by the same trained database specialist using standard denitions. Precision and accuracy were checked by chart review and procedures internal to the computer program. After identication of infants with pneumoe976 LITMANOVITZ, CARLO

thorax, the medical charts were reviewed for abstraction of additional relevant data. Infants who were not receiving assisted ventilation or continuous positive airway pressure, infants with congenital anomalies, and infants who required urgent chest-tube insertion during resuscitation or before transport to University of Alabama at Birmingham were not included in additional data analysis. Data analysis included demographic data (gestational age, birth weight), respiratory and radiologist diagnoses (unilateral, bilateral, or tension pneumothorax), and respiratory management, including ventilator settings and blood gases at baseline and the time it took for the pneumothorax to be diagnosed. Time to diagnosis was determined from the nursing and medical notes and the time the radiographs were done. Infant were divided into 2 groups according to their initial treatment: with or without chest-tube insertion. The group with no chest tubes was further subdivided into infants who initially received needle aspiration or expectant treatment. Infants who received needle aspiration as an intermediate step to get a chest tube (classied by chart review as physician intention and up to 2 hours) were classied as initial chest-tube insertion group. A repeated measure analysis of variance with posthoc Tukeys analysis was used to compare continuous variables among the 3 groups. The chest-tube and no-chesttube groups were also compared by t test. 2 tests were used to compare categorical variables among groups. All analyses were performed with SPSS 15 (SPSS Inc, Chi-

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TABLE 1 Pulmonary Diagnosis and Respiratory Support of Ventilated Infant With Pneumothorax
Parameter Chest Tube (n 101), n (%) No Chest Tube Needle Aspiration (n 14), n (%) 12 (86) 0 (0) 0 (0) 1 (7) 0 (0) 0 (0) 1 (7) 10 (77) 11 (85) 1 (8) 1 (8) 2 1 2 (14) 0 (0) 6 (46) Expectant Treatment (n 21), n (%) .46 77 (76) 4 (4) 8 (8) 4 (4) 3 (3) 1 (1) 4 (4) 70 (69) 71 (70) 24 (24) 6 (6) 5 6 26 (26) 6 (6) NA 14 (66) 1 (5) 0 (0) 2 (10) 2 (10) 0 (0) 3 (14) 10 (48) 17 (80) 2 (10) 2 (10) 2 3 1 (5) 1 (5) 2 (9) P

Respiratory diagnosis RDS TTNB Pulmonary hypoplasia PPHN MAS Pneumonia Pneumothorax Surfactant Respiratory support CMV HFV CPAP Age diagnosed, mean SD, d Tension pneumothorax Bilateral pneumothorax Failure of therapy

.30 .25

.01 .06 .20 .05

FIGURE 2 Day 3 radiograph showing a left-sided tension pneumothorax in a 1.1-kg infant who was intubated for respiratory distress syndrome.

RDS indicates respiratory distress syndrome; TTNB, transient tachypnea of the newborn; PPHN, persistent pulmonary hypertension of the newborn; MAS, meconium aspiration syndrome; CMV, conventional mechanical ventilation; HFV, high-frequency ventilation; CPAP, continuous positive airway pressure; NA, not assessed.

cago, IL). Data are presented as means signicance was set at P .05.

SD. Statistical

RESULTS Of the 14 614 infants who were admitted to the NICU during the study period, 307 (185 preterm and 119 term), or 2.1% (1.9% of preterm and 2.6% of term), had a pneumothorax (Fig 1). The medical charts of 14 infants could not been found for review, so the infants were eliminated from additional analyses. Thirty-seven infants had a chest tube inserted during resuscitation, 25 infants had a chest tube inserted before admission (in the referring hospital), 93 infants were not on respiratory support, and 2 infants had multiple congenital anomalies. The remaining 136 ventilated infants were divided into 2 groups according to the initial treatment of the pneumothorax: chest-tubetreated group (n 101 [74%]) and no-chest-tube group (n 35 [26%]). The no-chest-tube group was subdivided into infants who were treated initially with needle aspiration (n 14) or with expectant treatment (n 21). The term infants who were treated with or without a chest tube were of comparable gestational age and birth weight. The preterm infants who were treated without a chest tube were more mature (30 4 vs 27 4 weeks; P .001) and had higher birth weights (1653 718 vs 1109 654 g; P .001) than infants who were treated with a chest tube. Overall, the distribution of the respiratory diagnoses was comparable in the 3 groups (P .46; Table 1). A total of 76% of the infants who were treated without a chest tube and 74% of those who were treated with a chest tube had respiratory distress syn-

drome; however, all 8 infants with pulmonary hypoplasia were treated with a chest tube. There were no differences between the groups in the type of respiratory support (P .25). The pneumothorax occurred earlier during the hospital course in the infants with no chest tube (2 1 and 2 3 days in the aspiration and expectant-treatment group, respectively, vs 5 6 days in the chest-tube group; P .01). Among the 29 infants with a tension pneumothorax, 26 (90%) were treated with a chest tube, 2 received needle aspiration, and 1 received expectant treatment. Radiographs of the infant with a tension pneumothorax while on a ventilator and with subsequent spontaneous resolution are shown in Figs 2 and 3. Infants who were treated without a chest tube were on lower ventilator setting (mean airway pressure and fraction of inspired oxygen) compared with infants who were treated with a chest tube before the occurrence of the pneumothorax (P .05; Table 2). They also required a lower ventilator setting (mean airway pressure and fraction of inspired oxygen) when the pneumothorax was diagnosed and had better blood gas results (arterial oxygen saturation, PCO2, and pH) compared with infants who were treated with a chest tube (P .05). Analysis of variance with posthoc tests by the Tukeys method show that the differences were between only the expectant-treatment group and the chest-tube group. Of the 35 infants who were treated initially without a chest tube, 27 (77%) had resolution of the pneumothorax without additional intervention. Two (10%) infants from the expectant management group versus 6 (43%) infants from the needle aspiration group (P .05) rePEDIATRICS Volume 122, Number 5, November 2008 e977

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FIGURE 3 Day 5 radiograph showing spontaneous resolution of the pneumothorax. The infant was extubated on day 6.

ceived subsequent treatment with a chest tube 5 to 120 hours after the initial treatment because of the persistence of the pneumothorax without clinical improvement. DISCUSSION In this study, we found that 26% of the infants who had a pneumothorax while on a ventilator were initially

treated without chest-tube insertion. These infants were more mature, were on a lower ventilator setting, and had better blood gases at the time of the pneumothorax. A total of 77% of them did not require drainage with a chest tube. Thus, it is likely that the initial decision not to insert a chest tube was based on an assessment of the clinical status, and the least sick infants were treated without a chest tube initially. The need for a subsequent chest tube was lower for infants whose initial treatment consisted of expectant treatment rather than needle aspiration. Similarly, the least sick infants may not have had needle aspiration initially and instead received expectant treatment. This study is limited by its observational and retrospective design; however, we were able to use a reliable database that identied all infants with a pneumothorax. The clinical decisions for management of the pneumothorax, as well as for the denition of failure, were made by a diverse group of neonatologists with different approaches to the treatment of pneumothorax, so the actual incidence of patients who could be treated without a chest tube is likely to be higher because expectant treatment was not uniformly practiced on every possible occasion. Pneumothorax is a life-threatening condition with high mortality26 and morbidity.27 It has been suggested that early recognition and treatment are benecial to avoid damage as a result of hypoxemia, hypercapnia, and impaired venous return.1014,28 In our cohort, 12% of the infants presented with acute decompensation that required resuscitation. It is not clear from the literature how often a pneumothorax progresses rapidly and how often it resolves spontaneously in infants who are on positive pressure ventilation. To the best of our knowl-

TABLE 2 Respiratory Support and Blood Gas Parameters of Ventilated Infants With Pneumothorax
Parameter Chest Tube (n 101) No Chest Tube Needle Aspiration (n 14) 54 18 4.2 7.4 49 76 19 4.5 9.3 47 84 40 56 7.22 20 21 1 0.4 1.1 23 29 4 1.0 3.8 20 16 10 38 0.09 2 Expectant Treatment (n 21) 56 22 4.1 9.1 42 65 22 4.1 9.4 45 92 74 48 7.30 21 28 9 1.2 2.8 21 25 7 0.8 3.1 17 4 48 16 0.12 4 Analysis of Variance P Chest Tube vs No Chest Tube

Baseline respiratory support FIO2, % PIP, cm H2O PEEP, cm H2O MAP, cm H2O Rate, /min Respiratory support at diagnosis FIO2, % PIP, cm H2O PEEP, cm H2O MAP, cm H2O Rate, /min Blood gas parameters at diagnosis SaO2, % PO2, mm Hg PCO2, mm Hg pH Bicarbonate, mEq/dL
Data are means saturation.

67 21 4.1 10.8 46 92 23 4.3 11.6 53 77 50 67 7.16 20

27 8 1.1 4.1 25 16 8 1.2 4.0 25 18 31 26 0.19 6

.14 .62 .98 .09 .89 .001 .39 .69 .05 .24 .05 .05 .01 .01 .59

.05 .70 .99 .05 .90 .001 .30 .40 .05 .09 .01 .16 .05 .05 .40

SD. PIP indicates peak inspiratory pressure; PEEP, positive end-expiratory pressure; MAP, mean airway pressure; SaO2 oxygen

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edge, there are limited data to document the safety of expectant treatment of ventilated infants who present with a pneumothorax. Trevisanuto et al1 reported a series of 61 neonates with pneumothorax, 36% of whom were treated without chest tube (16% with needle aspiration and 20% with expectant treatment). Although 56% of the infants in the series were ventilated, it is not reported how many of those who were treated without chest tube were on a ventilator. Katar et al26 reported that 5 of 7 nonventilated term infants with symptomatic pneumothorax were treated without a chest tube, but all 4 infants with respiratory support (2 on continuous positive airway pressure and 2 on positive pressure ventilation) were treated with chest-tube insertion. Thus, our series is unique because it is the largest cohort of infants who had a pneumothorax while on ventilation and were treated without chest-tube insertion. The current success rate with expectant treatment was signicantly higher than with needle aspiration (90% vs 57%). It is possible that needle aspiration itself causes lung injury that results in worsening of the pneumothorax. Conservative management may be of particular benet when the medical personnel have limited experience with chesttube placement or needle aspiration. CONCLUSIONS We have documented a high success rate with expectant management of pneumothorax in a select group of ventilated infants with pneumothorax. Expectant management should undergo additional evaluation in studies of neonates with pneumothorax, particularly those who are on relatively lower ventilatory support and with acceptable blood gas levels. REFERENCES
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PEDIATRICS Volume 122, Number 5, November 2008

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Expectant Management of Pneumothorax in Ventilated Neonates Ita Litmanovitz and Waldemar A. Carlo Pediatrics 2008;122;e975; originally published online October 13, 2008; DOI: 10.1542/peds.2008-1269
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2008 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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