How do you DIAGNOSE and TREAT a newborn's PNEUMOTHORAX??!

Before we go on and before I lose you, I just want to say one thing, and that is that the diagnosis of a tension pneumothorax can only be made at bedside. You can't look at an x-ray and be like, oh, that's a tension pneumothorax. You might have a pretty good idea. But by definition, to be a tension pneumothorax, the amount of air needs to be impeding the venous return. So you have decreased venous return and therefore you have low blood pressure. And that is the marker of a tension pneumothorax. Hi, I'm Dr. Tala, and I've been a neonatologist for 16 years now. And today we're going to be talking about pneumothoraces or the collection of air right outside a baby's lungs. We'll be covering the incidence of pneumothoraces, the cause, the diagnosis, the management, and the outcomes. Remember to stick around to the end so that you can complete the homework assignment that we've got for you. And remember, if you do want a PDF summary of this video, then please subscribe to our newsletter and you'll get that for free. In following videos, we'll go over how to perform a needle thoracocentesis, as well as chest tube placement using a very willing dummy. Let's start with one. Who gets pneumothoraces? I think I'm going to use pneumothorax from now on because that's just a really weird word. Anyway, the incidence of infants who are getting a pneumothorax has really gone down in the last 20 years, probably because of our usage of a surfactant and then just more gentle ventilation, less positive pressure that we're using. In term babies, the incidence is somewhere between 0.02 and 0.1%, which is about one in 1,000 to 5,000 births. Most of these babies will have an underlying lung disease. For example, TTN, transient tachypnea of the newborn, or meconium aspiration syndrome, or a CDH, a congenital diaphragmatic hernia, or they could have pulmonary hyperplasia because they didn't have any amniotic fluid during the pregnancy, whether there was renal agenesis or whether there was a PPROM a long time ago. Or the babies could have had CPAP or PPV given to them, positive pressure ventilation given to them in the delivery room. If a baby has an underlying lung disease and then gets a pneumothorax, then this is considered a secondary pneumothorax. Sometimes, occasionally, babies who are otherwise very well and healthy may end up having increased work of breathing and you work them up and get an x-ray and see that they do have a pneumothorax and this is considered a primary or a spontaneous pneumothorax. Most of these are thought to happen because of differences in pressure in the lungs and outside the lungs immediately after the baby is born. As we've all seen, premature babies are way more likely to get pneumothoraces or a pneumothorax because they are much more likely to have RDS or respiratory distress syndrome and they're much more likely to be under some sort of positive pressure, whether it's CPAP or NIPPV or whether they're actually intubated. And when babies are under positive pressure and they're kind of fighting against it, then you end up with that mismatch of pressures and you're much more likely to end up with a pneumothorax. Tiny babies can also get PIE or pulmonary interstitial emphysema, which is another air leak syndrome and can also kind of make it more likely that a baby is going to end up with a pneumothorax. In a nutshell though, basically, prematurity and RDS are the two most common causes of babies getting a pneumothorax. Weirdly as well, pneumothoraces happen more commonly in males than females. What causes a pneumothorax? So the lungs, look at my lovely model, are covered with a thin layer of tissue called the visceral pleura. Oh, my liver's falling out. So covered with a thin layer of tissue called the visceral pleura. And then the inside of the chest wall is covered with another thin layer of tissue called the parietal pleura. And this is brilliant engineering because as the lungs open and close, then you get these tissues kind of sliding nicely alongside each other without causing scratching or irritation or inflammation. But having these two layers of tissue between the chest wall and the lungs means that that pressure needs to be very well regulated within that space. Sometimes if there's too much of a sucking space in the pleural space, or there's too much mismatch positive pressure in the lungs, then what can happen is that you can get a rupture or the alveoli, the lungs will literally pop. The air will get out and then it will collect in the space between the pleura. So that is what a pneumothorax is. When you have a collection of air in the pleural space. The thing is though, air can get in that way, but air can't get out that way. So what can happen is that this air grows bigger and bigger and bigger in that space and starts pushing down on the lungs. And so obviously if the lungs are collapsed, then the baby's going to end up in respiratory distress. If the lungs are completely collapsed and there's so much air building up that it's now impeding venous return, then you end up with a tension pneumothorax. And that is when the blood literally can't get back to the heart. So there's decreased cardiac output and the baby's hypertensive. Obviously this is very dangerous and it is an absolute emergency to try to get rid of that air. Three, how do we diagnose a pneumothorax? Well, it's possible that some babies may have just little tiny spontaneous pneumothoraces and they just kind of go away by themselves and we never even know about it. But logically, most of the time, if a baby does have a pneumothorax, then they're going to end up with some level of respiratory distress. So the baby might have tachypnea, breathing fast, might be having retractions, maybe grunting, maybe desaturating. So the oxygen saturations go down on the baby. Just general increased work of breathing. If the baby is already on support, then their gas might get a lot worse. They might need increased settings. The FiO2 might go up significantly. So A, we diagnose with a physical exam. So you can see the increased work of breathing. And then when you put the stethoscope on and actually listen to the baby's lungs, then you may hear breath sounds much better on one side, whereas on the side with a pneumothorax, you might not be hearing breath sounds at all. Sometimes this is super obvious. Other times though, the baby might have really bad breath sounds anyway, or one side could just be completely collapsed or there's just complete atalactosis and you're not going to hear good breath sounds. So generally, I wouldn't go sticking needles in based on just listening to the lungs with a stethoscope. B, the second way to, and probably the second quickest way to diagnose a pneumothorax is with transillumination. So you just basically need a flashlight. We love the ones that you use to like put in IVs or peripheral art lines. And then you take that flashlight and starting kind of under the armpit or under the axilla, just like pointed up under the skin all the way down to the diaphragm. If a baby does have a pneumothorax, then that side should glow a lot brighter than the other side that doesn't have a pneumothorax. So often you're checking both sides to kind of compare it to. Sometimes though this can yield false positives. For example, if it's a really tiny baby, then honestly, everything just kind of glows bright on those tiny ones, or the patient might just have like a pneumomediastinum, which is just a collection of air around the mediastinum that could also yield false positives as well. However, if the baby is really crashing, you don't have time to do anything else. And one side glows really brightly with a transillumination that probably is enough to stick in a needle to try to see if you can drain anything. C, x-rays. And honestly, where we are right now, this is probably the most common way how we diagnose pneumothoraces. You should probably always get an x-ray when you admit a baby to the NICU with respiratory distress or an oxygen requirement, just because you're honestly never sure if that baby does have a pneumothorax or something else weird or not. We did film a video on x-rays of babies with different lung disease. So go watch that if you want to see what a bunch of x-rays of babies with pneumothoraces look like. But basically, the pneumothorax might be just really subtle. So a pneumothorax is a sliver of air, which is going to appear black on the x-ray. Sometimes it's just a tiny little bit of black right outside the lungs. And the only way that you can really tell is by seeing whether the lung markings kind of go to the edge of the chest wall. Sometimes that collection of blackness or that collection of air outside the lungs is absolutely massive. And it's pushing on the lungs. And you might even have mediastinal shift, where kind of like all the middle part of the lungs is moving over to the other side. Obviously, in those cases, it's a lot more obvious. I just want to add this. Sometimes on those kind of portable x-ray machines, when you can look down at the x-ray as it's being taken, sometimes you can miss a pneumothorax. They're not necessarily as sensitive to kind of seeing all the line, the lung markings towards the edge. So you can over-call it and under-call it on that. So try to get your reading in a place where you can kind of play around with the lightness and darkness of the x-ray to really get a good look at those lung markings. D, point-of-care ultrasounds. So this is kind of like a more recent phenomenon. And you can imagine how great it would be to just use an ultrasound at bedside really quickly to be able to diagnose a pneumothorax, especially in a really sick baby. It's quick and it doesn't involve any radiation at all. I just attended a quick point-of-care ultrasound course by Drs. Ruos and Drs. Altit, who taught it so well that they made it seem so very easy and so straightforward to actually especially diagnose a pneumothorax at bedside. So thank you. Definitely a skill that we can all learn and something that we really should all work towards because ultimately that probably is the quickest way that we can diagnose a pneumothorax. Obviously, it's operator dependent, so we all have to work on that skill. Four, management. How do we actually manage and treat pneumothoraces? As you can probably imagine, that's really going to depend on several factors. If the pneumothorax is really small, so just a sliver, or the baby only has like mild increased work of breathing, maybe the baby's on low support, maybe like room air or a nasal cannula, then in some situations, in a lot of situations, we may just observe the pneumothorax and we don't actively do anything differently about it. Eventually, we hope that the lung will heal so that like a little rupture in the alveolus will just slowly heal by itself. And obviously, we also hope that the air that's trapped within the pleural space just slowly gets reabsorbed. So we're hoping that by not doing anything, then the pneumothorax will slowly go away by itself and the lungs will heal. Obviously, if you're just monitoring the pneumothorax, then it's very important to closely monitor the clinical status of the baby. So if it looks like the baby's getting sicker, increased respiratory distress or something, get another x-ray or an ultrasound or whatever so that you can re-evaluate the size of that pneumothorax. Even if the baby is clinically stable, then we should be following serial x-rays to make sure that that pneumothorax does go away. Something we used to do in the past with kind of smaller pneumothoraces is give babies 100% oxygen, whether it was like in an oxy herd, which we don't use anymore, or 100% with a nasal cannula. So the logic was that if we're just giving 100% oxygen and that's accumulating in that pleural space, then it's a lot easier for the blood to absorb oxygen rather than nitrogen, which makes up most of the air. So the thought was, was that the pneumothorax would be absorbed easier if it was 100% oxygen. And this was actually found to be helpful in adults, but as we've all learned, 100% oxygen, especially for our neonates is not good for anyone. If the baby is struggling, or we see that the pneumothorax is getting a lot bigger and we feel that the increased work of breathing is secondary to the pneumothorax, then at some point that air needs to be evacuated the pleural space so that the lungs can re-expand again. So at some point that air needs to be drained. And as you all know, there are different ways that we can do this. We can start with a needle thoracocentesis, which is where you basically take a little needle and you inject it at the level of the kind of second and third intercostal space in the mid clavicular line. And then you push that needle through the chest wall into the pleural space and suck out whatever air you can get. So it could be 10 mLs of air. It could be a hundred mLs of air. Once you feel like you're not sucking out any more air, then you actually remove the needle at the same time. We'll either use a butterfly or we'll use an angiocath. In the bigger babies, obviously we're using the angiocath because sometimes the butterfly just kind of can't reach through to that space. Sometimes removing this air once is just enough to do the trick. One study showed that, however, this only works in about 20% of the time. And often, unfortunately that air kind of just all reaccumulates. Because remember, even though you're getting rid of the air, you haven't actually resolved the issue with a rupture in the alveolus. So that air is still leaking through the lungs into the pleural space. If that air does reaccumulate and the baby's in distress again, then we have to put something more permanent in. So we'll put in a chest tube and leave that in there so that it's continuously draining out the air until that alveolus or the lung has healed. In those cases, we'll put in a chest tube. So a pigtail or a trocar, and we'll go over those in a coming video in like the fourth to sixth intercostal space, which is more in the mid-xillary line. And we'll keep that in and then use suction probably initially continuously to continuously try to get that air out. So we'll set it up to suction, maybe 10 to 20 centimeters of water. Then we'll follow serial x-rays and we'll keep the chest tube to suction until it looks like that pneumo's gone away. Once the pneumo's gone away, then we can put that tube to water seal. So it's no longer sucking anything out. If the pneumothorax doesn't reaccumulate, then at that point we can say, okay, most likely the alveolus has healed and we don't need to keep the chest tube in any longer. And at that point we can pull out the chest tube. Another couple of management tips you should consider if a baby has a pneumo. The first one is, is you should be thinking what actually caused this baby to have a pneumo. Was it RDS or meconium aspiration syndrome? If it was one of those two, then you have to kind of think it's probably pressure differences between the baby and between the positive pressure and everything that we're giving, as well as the actual etiology of the disease that's going to make it very likely that a baby could get another pneumothorax, even if you get rid of this one. So with RDS and meconium aspiration syndrome, then you should be considering giving a dose of surfactant or if they've already had one, then maybe wait 12 hours or whatever after the last one and give another dose of surfactant. The second point is, is that these are babies when they do have a pneumothorax, that you want to be as gentle as possible with their ventilation. So you really want to lower the overall pressures that you're giving the baby so that it gives the alveoli a chance to heal. And so that you're not pushing more air into that intrapleural space. So for example, if you're on the jet, then decrease the PEEP, decrease the PIP, decrease the rate. If the baby's on a backup rate, definitely stop that. Same thing if a baby is on a conventional ventilator, decrease the pressure. So the PIP and the PEEP and decrease the eye time, even if you have to accept a slightly higher FiO2. Some studies have suggested that babies will do better if we switch from a pressure control to a volume guarantee mode on the conventional ventilator. If you're on CPAP, then evaluate whether these babies can actually be weaned to high flow nasal cannula. Even if you're kind of going up a lot more in the flow than you'd normally want to when you come off CPAP. So you're on CPAP of six and you might try to go to high flow nasal cannula of seven or eight, just so that you can kind of be blowing less positive pressure into the baby's lungs, hoping that the pneumothorax is more likely to heal by itself. Five, outcomes. Obviously we'd prefer it if a baby never got a pneumothorax, but generally term babies do really well, even if they do end up getting a pneumothorax. It does however end up increasing their length of hospitalization and one study showed that it increases it by a median of four days. It goes without saying that if a baby has a pneumothorax, then it definitely has to be diagnosed and recognized so that you can do something about it. Obviously if it's missed and that pneumothorax gets bigger and bigger, then babies can die of a tension pneumothorax. So obviously the outcome is going to be very good if it's diagnosed and adequately managed. In preterm babies, we worry about pneumothoraces a lot more and one of the biggest concerns is that once there is increased pressure in the lungs, pushing on or outside the lungs, pushing on the lungs, then what you're worried about is that there is impedance or in some way you are affecting the venous return, whether it's the blood coming back from the head or whether it's the blood going to the heart. So as soon as you start worrying about pressure changes in the chest, then what this can translate to is an increased risk of intraventricular hemorrhages and that has been shown that if a baby does have a pneumothorax, a preemie baby, they have a higher risk of getting an IVH. Obviously if your lungs aren't great in the first place and you get a pneumothorax, it's going to make the lungs significantly worse and in a preemie baby that could be really bad and really increase the risk of the baby getting persistent pulmonary hypertension. Having a pneumothorax in a premature baby in itself increases the risk of mortality. You have to also imagine that those are also the generally the sicker babies that are going to end up with a pneumothorax so definitely that comes into play but various studies have shown that a pneumothorax in a preemie baby has a mortality rate of somewhere between 16 and 65 percent which all of it seems outrageously high but just take away from the fact that it does increase mortality. Okay that was it so let's go over your homework assignment. 1. Describe what causes a pneumothorax. 2. Name three scenarios where babies are more likely to get a pneumothorax and 3. Name three treatment options for infants with a pneumothorax. I hope you enjoyed that. If you got this far then please like this video and subscribe to our channel if you're interested in all types of neonatal education. Thanks so much for being here.