What is the management plan for a term neonate with a loculated pneumothorax?

Management of Loculated Pneumothorax in Term Neonates

The management of a term neonate with loculated pneumothorax should include chest tube placement with consideration for intrapleural fibrinolytic therapy to break down loculations and improve drainage. 1, 2

Initial Assessment and Management

• Prompt diagnosis is critical and should include:

  • Transillumination of the chest
  • Chest X-ray
  • Lung ultrasound (helpful for identifying loculations) 3

• Immediate intervention for unstable neonates:

  • Supplemental oxygen to maintain saturation >90% 4
  • Chest tube placement is the primary intervention for loculated pneumothorax 1

Chest Tube Management

Tube Selection and Placement

• Small-bore catheter (≤14F) or moderate-sized chest tube (16F-22F) is appropriate for most term neonates 2, 1
• Proper analgesia must be provided:
  • Infiltration of the skin site with local anesthetic before incision 2
  • Consider opioid administration for additional pain control 2

Drainage System

• Connect the chest tube to either:

  • Water seal device (with or without suction)
  • Heimlich valve (for stable patients) 2, 1

• Apply suction (5-10 cm H₂O) if:

  • The lung fails to re-expand quickly with water seal alone
  • There is a significant air leak
  • The pneumothorax is large or under tension 1

Management of Loculations

• Intrapleural fibrinolytic therapy is recommended for loculated pneumothorax 2

  • Fibrinolytics lyse fibrinous strands in loculations, clearing lymphatic pores and restoring normal pleural fluid dynamics
  • Urokinase has the strongest evidence in pediatric patients 2
  • Alteplase (tissue plasminogen activator) is an alternative, especially in regions where urokinase is unavailable 2

• Blocked chest tube management:

  • If the tube becomes blocked (common with loculations), flush carefully with normal saline (10 ml is adequate for a small-bore drain) 2
  • A permanently blocked drain should be removed and replaced if significant pleural fluid remains 2

Monitoring and Tube Removal

• Monitor for clinical improvement:

  • Respiratory rate and effort
  • Oxygen saturation (mortality is high in neonates with persistent saturation <90%) 4
  • Chest radiographic appearance

• Remove the chest tube when:

  • Clinical resolution is achieved
  • Chest radiograph confirms lung re-expansion
  • Air leak has resolved 2, 1

• Technique for tube removal:

  • Provide adequate analgesia (local anesthetic cream applied 3 hours before removal is as effective as IV morphine) 2
  • Remove during expiration with a brisk, firm movement 2, 1
  • Obtain a chest radiograph shortly after removal to ensure a pneumothorax has not developed 2

Special Considerations

• Persistent respiratory distress despite chest tube placement may indicate:

  • Inadequate drainage due to loculations
  • Development of persistent pulmonary hypertension (PPHN), which requires prompt recognition and possible referral to tertiary care 5

• Expectant management (observation without drainage) is generally not appropriate for loculated pneumothorax, as studies show that invasive intervention is often necessary 6

• Mechanical ventilation may be required in up to 60% of neonates with pneumothorax 4

  • Use gentle ventilation strategies to minimize barotrauma
  • Maintain airway pressures within safe limits 1

Follow-up Care

• Obtain follow-up chest radiograph 2-4 weeks after discharge 1
• Advise parents to seek immediate medical attention if the infant develops increased respiratory distress 1

The management of loculated pneumothorax in term neonates requires prompt diagnosis and intervention, with chest tube placement being the cornerstone of treatment. The addition of fibrinolytic therapy should be strongly considered to break down loculations and improve drainage, potentially shortening hospital stay and reducing morbidity.