From the Guidelines
Pulmonary interstitial emphysema (PIE) in neonates should be managed with gentle ventilation strategies, prioritizing reducing barotrauma and minimizing positive end-expiratory pressure (PEEP) to 4-5 cmH2O, as supported by recent guidelines 1. The primary approach involves decreasing peak inspiratory pressures, using high-frequency ventilation, and conventional ventilation with rates of 60-100 breaths per minute and low tidal volumes (3-4 mL/kg). High-frequency oscillatory ventilation may be beneficial with settings of 10-15 Hz frequency, mean airway pressure of 8-12 cmH2O, and amplitude adjusted to achieve visible chest wall vibration. Some key considerations in the management of PIE include:
- Reducing barotrauma through gentle ventilation strategies
- Minimizing PEEP to 4-5 cmH2O
- Using high-frequency ventilation and conventional ventilation with low tidal volumes
- Considering selective bronchial intubation of the unaffected lung for unilateral PIE
- Providing supportive care, including maintaining adequate oxygenation (target SpO2 90-95%), careful fluid management, and positioning the patient with the affected side down when PIE is localized. It is essential to recognize that PIE can progress to pneumothorax and pneumomediastinum if left untreated, highlighting the need for early recognition and intervention 1. In severe cases unresponsive to ventilation strategies, surgical interventions like lobectomy might be necessary, though this is rare. The use of exogenous surfactant may improve lung expansion and reverse PIE, particularly in infants with meconium aspiration syndrome or other significant parenchymal disease, as noted in guidelines for pediatric pulmonary hypertension 1. However, the decision to use surfactant should be made cautiously, considering the potential risks and benefits, and the most recent evidence should guide this decision 1.
From the Research
Diagnosis of Neonatal Pulmonary Interstitial Emphysema (PIE)
- PIE is a pathological state when air escapes from ruptured alveoli and is trapped along the sheaths surrounding the bronchovascular bundle 2
- It is a frequent complication in preterm-ventilated infants, who have an increased risk of mortality and bronchopulmonary dysplasia 3
- Diagnosis can be confirmed by chest radiograph and chest computerized tomography 2
Treatment of Neonatal Pulmonary Interstitial Emphysema (PIE)
- Various treatments for PIE have been proposed, including:
- Conservative approach should remain the first choice treatment of unilateral PIE in order to limit surgical procedures 3
- Positional therapy alone can be an effective treatment for unilateral PIE, with significant clinical and radiographic improvement noticed within a few days 2, 4
- Selective lung ventilation can be a therapeutic option for refractory PIE 5
- Therapeutic lung puncture with consecutive tension release of the overinflated lung by drainage is a therapeutic option for premature infants suffering from diffuse PIE in whom other conservative measures fail 6