From the Guidelines
The best next step in management of this premature infant with acute respiratory distress is to perform needle thoracostomy (option F). This 2-day-old girl has developed sudden respiratory deterioration with grunting, tachypnea, hypoxemia, decreased breath sounds on the left, and positive transillumination of the left chest, which are classic signs of a pneumothorax. The shift of heart sounds to the right side further supports this diagnosis. Pneumothorax is a life-threatening emergency in premature infants, especially those on positive pressure ventilation like nCPAP, as noted in studies such as 1 and 1, which highlight the risks associated with CPAP in preterm infants.
Needle thoracostomy provides immediate decompression of the trapped air, allowing the collapsed lung to re-expand and improving oxygenation. This should be performed before obtaining imaging studies when clinical signs strongly suggest tension pneumothorax with hemodynamic compromise. The procedure involves inserting a needle into the second intercostal space at the mid-clavicular line on the affected side. Following emergency decompression, a formal chest tube placement would typically be performed for continued management. Premature infants on respiratory support are at increased risk for air leaks due to their immature lung development, despite surfactant administration, as discussed in 1 and 1.
Key considerations in this scenario include:
- The clinical presentation of pneumothorax, which is a medical emergency requiring prompt intervention.
- The increased risk of pneumothorax in premature infants on positive pressure ventilation, such as nCPAP, as highlighted by studies including 1.
- The importance of immediate decompression to prevent further complications and improve outcomes, as would be the priority in real-life clinical practice, especially when the evidence from studies like 1 and 1 supports the potential benefits and risks of different respiratory support strategies in preterm infants.
From the Research
Patient Assessment
The patient is a 2-day-old girl in the neonatal intensive care unit due to prematurity and respiratory distress. She was born at 29 weeks gestation and has been receiving surfactant replacement, nasal continuous positive airway pressure (nCPAP), and intravenous fluids. The patient has developed an acute onset of grunting and increased work of breathing, with a respiratory rate of 70/min and pulse oximetry of 80%. Lung examination shows decreased breath sounds on the left and intercostal retractions.
Diagnostic Findings
Bedside transillumination shows increased brightness on the left chest relative to the right, suggesting a pneumothorax. The cardiac examination reveals heart sounds that are loudest over the right side of the chest and no murmurs.
Management Options
The best next step in management of this patient is to relieve the tension pneumothorax. The options include:
- Discontinue nCPAP
- Increase nCPAP end expiratory pressure
- Initiate chest physiotherapy
- Obtain echocardiogram
- Order chest radiograph
- Perform needle thoracostomy
Recommended Course of Action
Based on the patient's symptoms and diagnostic findings, the most appropriate course of action is to perform a needle thoracostomy to relieve the tension pneumothorax 2, 3, 4, 5. This procedure is a valuable adjunct in the management of tension pneumothorax, a life-threatening condition. However, it is essential to consider the potential complications of needle thoracostomy, such as failure to access the pleural space, especially in patients with a thicker chest wall 3, 4, 5.
Key Considerations
When performing a needle thoracostomy, it is crucial to consider the appropriate catheter length and puncture site to ensure successful access to the pleural space 4, 5. The use of computed tomography scans can help determine the optimal catheter length and puncture site based on the patient's chest wall thickness 3, 4, 5. Additionally, chest X-ray can be used to predict the need for tube thoracostomy in patients with traumatic pneumothorax 6.