Localized Pulmonary Interstitial Emphysema Research Articles

Resolution of localized pulmonary interstitial emphysema in two neonates - Why does neurally adjusted ventilatory assist work?

Localized pulmonary interstitial emphysema (PIE) is a known complication of mechanical ventilation. Recently, we encounter two cases of localized PIE, which developed on the course of mechanical ventilation using high-frequency oscillatory ventilation, followed by conventional intermittent positive pressure ventilation. We then switched the ventilator mode to neurally adjusted ventilatory assist (NAVA). We observed that on switching to NAVA, there was a decrease in peak inspiratory pressure (PIP) in case 1 and case 2, and decrease in tidal volume in case 2. Localized PIE resolved in 6-9 days' time. Since high PIP and high tidal volume are risk factors for PIE, NAVA could lead to resolution of localized PIE by achieving lower PIP and lower, but optimal tidal volume. We suggest that NAVA is a treatment of choice in localized PIE.

PULMONARY LOBAR INTERSTITIAL EMPHYSEMA

Pulmonary interstitial emphysema is a relatively common entity in neonatal intensive care units. It can occur in full-term babies but more frequently occurs in premature infants receiving positive pressure ventilation. The process can be localized or diffuse, and the diagnosis is based on the presence of air in the interstitial pulmonary tissue, observed by radiology. The localized form is more rare and one or more lobes may be involved in the process. Our case report is of a second twin male, born after 33 weeks of gestation. After birth, a mild respiratory distress was installed, and the patient was treated with nasal continuous positive airway pressure. After two pneumothoraces, an image of diffuse cystic changes was observed in the right upper lobe. The patient was operated with the clinical and radiologic diagnosis of cystic adenomatoid malformation. The histological study of the resected lobe, by light and scanning electron microscopy, revealed a localized pulmonary interstitial emphysema.

Localized pulmonary interstitial emphysema: treatment by bronchial occlusion.

Selective bronchial occlusion for the treatment of localized cystic pulmonary interstitial emphysema (PIE) offers a means to facilitate weaning from ventilatory support and to preserve potentially functional lung parenchyma. We employed a commercially manufactured balloon catheter, placed under direct visualization to occlude a left mainstem bronchus in two cases of localized PIE. This is the safest method for selective bronchial occlusion so far reported. Therapeutic success was achieved with either continuous or intermittent bronchial occlusion. Evaluation of pulmonary function with nuclear scintigraphy aids in determining the most appropriate position for the occluding catheter and permits assessment of the resultant improvements in pulmonary function.

Optimal Endotracheal Tube Tip Position in Extremely Premature Infants

Although right main bronchus intubation is associated with adverse consequences, the optimal endotracheal tube (ETT) tip position above the carina in neonates is not known. The aim of this study was to determine the association between ETT tip position and adverse pulmonary effects as assessed by chest radiographs (CXRs). Lung aeration was examined after masking ETT positions in the first two CXRs taken after birth in 74 consecutive ventilated premature infants <or= 28 weeks. All the CXRs of the infants during the first week were examined for predefined combined adverse pulmonary outcomes by two examiners (right upper lobe collapse, localized pulmonary interstitial emphysema [PIE], and pneumothorax). Infants who had ETT tips below T4 or in the right main bronchus were excluded. The ETT tip was above T1 in 4 (5.4%), at T1 in 11 (14.8%), at T2 in 19 (25.6%), at T3 in 27 (36.5%), and at T4 in 13 (17.6%) infants. The patients were categorized into group A (ETT tips at T1/2) or group B (ETT above T1 or below T2). The combined adverse pulmonary outcome of pneumothorax, localized PIE, and right upper lobe collapse was significantly higher in group B compared with group A ( P=0.03). On logistic regression analysis, the only independent association for adverse pulmonary outcome and asymmetrical lung aeration was the ETT position. The odds ratio for developing nonuniform lung aeration was 6 (95% confidence interval [CI] 1.8, 20) and for adverse pulmonary outcome was 8 (95% CI 1.1, 73) when the ETT tip was at T3/T4 compared with T1/2. We concluded that the ETT tip should be kept at the level of the first or second thoracic vertebrae in extremely premature babies to reduce the incidence of nonuniform lung aeration and adverse pulmonary outcomes.

Intérêt et limites de l’obstruction bronchique sélective dans l’emphysème interstitiel unilatéral néonatal

Two methods of selective ventilation have been used for treating severe localized pulmonary emphysema in the neonates: controlateral selective intubation and selective bronchial obstruction. Three neonates with acute respiratory distress required respiratory support that was complicated by development of severe localized pulmonary interstitial emphysema of the right lobe (two cases) and the middle lobe (one case). Selective bronchial obstruction with a Swann Ganz catheter SF was tentatively made: in one case, improvement was moderate and transitory, requiring middle lobectomy. The localized emphysema disappeared within 3 days in the two other cases but a localized emphysema appeared in the controlateral lung in one of them, requiring left inferior lobectomy because the ineffectiveness of selective intubation or selective obstruction. Selective bronchial obstruction may fail but this easy and well tolerated method should be tried in severe localized emphysema, specially in those patients who cannot be ventilated with high-frequency oscillation.

Exchange transfusion using washed red blood cells reconstituted with fresh-frozen plasma for treatment of severe hyperkalemia in the neonate

Typically, patients who showed no improvement with lateral decubitus positioning already had widespread bilateral pulmonary injury and were not good candidates for either selective bronchial obstruction or intubation. Whether Iobectomy or pleurotomy would have been beneficial is uncertain, but this would certainly have involved substantial risk in these critically ill neonates. Although lateral decubitus positioning frequently necessitated minor adjustments of ventilatory support, our patients tolerated it well and responded to this therapy. Our observations are in agreement with recent research 1~ that indicates that when infants are placed in the lateral decubitus position, the uppermost good lung receives a greater portion of ventilation. Thus, the lateral decubitus position appears to be a relatively benign, noninvasive therapeutic maneuver that should be attempted before more invasive methods are used to treat serious focal pulmonary interstitial emphysema. REFERENCES 1. Campbell RE: Intrapulmonary interstitial emphysema: A complication of hyaline membrane disease. Am J Roentgenol Rad Ther Nucl Med 110:449, 1970. 2. Leonidas JC, Hall RT, Rhodes PG: Conservative management of unilateral pulmonary interstitial emphysema under tension. J Pediatr 87:776, 1975. 3. Broo]~s JG, Bustamante SA, Koops BL: Selective bronchial intubation for the treatment of severe localized pulmonary interstitial emphysema in newborn infants. J Pediatr 91:648, 1977. 4. Dickman GL, Short BL, Krauss DR: Selective bronchial intubation in the management of unilateral pulmonary interstitial emphysema. Am J Dis Child 131:365, 1977. 5. Fletcher BD, Outerbridge EW, Youssef S, Bolande RP: Pulmonary interstitial emphysema in a newborn infant treated by lobectomy. Pediatrics 54:808, 1974. 6. Magilner AD, Capitanio MA, Wertheimer I, Burko H: Persistent localized intrapulmonary interstitial emphysema: An observation in three infants. Radiology 111:379, 1974. 7. Levine DH, Trump DS, Waterkotte G: Unilateral pulmonary interstitial emphysema: A surgical approach to treatment. Pediatrics 68:510, 1981. 8. Matthew OP, Thach BT: Selective bronchial obstruction for treatment of bullous interstitial emphysema. J Pediatr 96:475, 1980. 9. Swischuk LE: Bubbles in hyaline membrane disease. Radiology 122:417, 1977. 10. tteaf DP, Melms P, Gordon I, Turner HM: Postural effects on gas exchange in infants. N Engl J Med 308:i505, 1983.

Selective bronchial intubation for the treatment of severe localized pulmonary interstitial emphysema in newborn infants

As an alternative to lobectomy and in order to preserve lung tissue which may be potentially functional we have selectively intubated the right main bronchus in four infants 12 to 25 days old with severe, pulmonary interstitial emphysema of the left lung. In each case the localized hyperinflation disappeared within 5 to 48 hours of contralateral selective bronchial intubation. The duration of SBI was 1.5 to 5 days. Three patients benefited from the procedure; there were no serious complications. We propose that SBI should be tried in infants with severe, localized PIE which has caused mediastinal shift, compressive atelectasis, and respiratory acidosis requiring mechanical ventilation despite vigorous pulmonary therapy and usual supportive measures.