Respiratory distress syndrome and ventilation complications in preterm neonate
Presentation
Very preterm birth, sparse antenatal checkup.
Patient Data
Day of birth
1 day later
ETT tip at level of carina
UVL in the IVC
UAL in the descending thoracic aorta
minimal improvement in aeration
early stage of pulmonary interstitial emphysema (PIE)
hepatomegaly
later on same day
PIE without pneumothorax
1 day later
PIE without pneumothorax
later on same day
PIE
chest and abdominal wall edema
free intraperitoneal fluid, fluid in bowel
3 days later
ETT tip at level of T1
left tension pneumothorax
PIE
dilated bowel loops
later on same day
chest drain on left, side hole outside thoracic cage
decrease in the size of the pneumothorax, with decrease in tension
subcutaneous emphysema on left
1 day later
chest drain raised high up on left
ETT tip at level of T2
improvement in left pneumothorax
PIE
distended, gas-filled bowel without sign of obstruction
3 days later
ETT tip at level of T2
chest drain located high in left hemithorax
left tension pneumothorax
PIE
later on same day
second chest drain inserted into left hemithorax , with substantial decrease in the size of the pneumothorax
10 days later
x-ray taken 10 days later:
substantial worsening of aeration
except for vascular recruitment to the right lung, right upper lobe (RUL) infiltrate has formed, perhaps due to aspiration
1 month later
x-ray taken 1 month later:
pulmonary vessel overload has developed in response to chronic lung disease (CLD)
Case Discussion
Very preterm birth (28w+3d). Mother was admitted for preterm premature rupture of membranes (PPROM). Treated with full course of steroids, antibiotics, magnesium, and nifedipine. Postpartum head ultrasound (not shown) - intraventricular hemorrhage (IVH) grade 3 in right ventricle and 2 in left ventricle. Protracted hemodynamic instability, treated with amines. Treated with acetaminophen for a large PDA.
Severe peripartum respiratory distress syndrome (RDS), treated with high frequency ventilation and surfactant. received NO for recalcitrant pulmonary hypertension. Developed barotrauma presenting as pulmonary interstitial emphysema (PIE). Treated with systemic steroids and inhalation, as well as diuretics. Treated with positive pressure ventilation until 69th day then later weaned off ventilatory support. Treated with caffeine. Moderate CLD at discharge.
Abdominal ultrasound before discharge was normal and demonstrated no free intra-abdominal fluid.
In preterm neonates, PIE and tension pneumothorax are well-known complications of positive pressure ventilation. Long-term sequelae are termed bronchopulmonary dysplasia (BPD) or chronic lung disease (CLD).
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