Case 2: Refractory Respiratory Failure and Pneumothorax in a Full-Term Newborn

Abstract

A female infant with a birthweight of 2,925 g is delivered at 38 6/7 weeks of gestation by a 32-year-old gravida 1, para 1 mother. The pregnancy is uncomplicated, and the mother’s evaluation for infection before delivery is negative. The birth occurs via precipitous vaginal delivery and is uneventful except for terminal meconium. At delivery, the infant is initially vigorous with an appropriate heart rate and tone, but she subsequently requires resuscitation because of increased work of breathing and oxygen saturation in the low 60s. She is treated with positive pressure ventilation, and the fraction of inspired oxygen is increased to 100%. Despite positive pressure ventilation, her physical examination findings and oxygen saturation do not improve. Her 1- and 5-minute Apgar scores are 7 each. Initial chest radiography shows a right-sided pneumothorax and pneumomediastinum. Her first capillary blood gas is notable for a pH of 6.9, a partial pressure of carbon dioxide (Pco2) of 101 mm Hg (13.4 kPa), and a base deficit of 13. Needle decompression of the right chest is attempted, after which the infant is intubated and mechanical ventilation is started. Screening infectious laboratory tests are performed and empirical broad-spectrum antibiotics are started. The infant is then transferred to a tertiary care facility for further care. Upon arrival, the infant is switched to a high-frequency oscillator. At this point, repeat chest radiography shows bilateral pneumothoraces and pneumomediastinum, so bilateral chest tubes are …