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 Published: 29/11/2011

Air leak syndromes

Pneumothorax Pulmonary Interstitial Emphysema Pneumatocoele


CXR - Pneumothorax.jpg (124088 bytes)

CXR - Pneumothorax 2.jpg (198671 bytes)

A pneumothorax may be seen as an isolated finding in an infant with respiratory distress, or may be associated with other forms of lung disease (particularly RDS and MAS).  The findings can be subtle with just minimal differences in lucency of lung fields.

Pneumothorax in a ventilated infant may be an emergency if it is under tension.  In the circumstance (as shown in the top image), urgent drainage prior to a radiograph is indicated.

Risk factors for pneumothoraces include:

However, up to 2% of infants can develop spontaneous pneumothoraces at birth.  These are thought to be secondary to the high pressures that infants can generate themselves when initiating breathing.  Many infants have minimal or no symptoms and the air leak resolves spontaneously over time.

The administration of 100% oxygen to term infants ("nitrogen washout") is said to potentially resolve the pneumothorax more rapidly.  The theory is that nitrogen in the air contained in the pleural space passively diffuses across lung into alveoli full of 100% oxygen.  This encourages resolution of the intrapleural air leak.  It is said that if this treatment is given, the pneumothorax will resolve in 48 hours instead of the 2 days it will take if you just leave it alone (.... think about it).

CXR - Bilateral pneumothorax.jpg (336469 bytes)

CXR - Bilateral PTx post-ICD.jpg (255435 bytes)

These images to the left are from a term infant born by caesarean section at term.  The baby had respiratory difficulty from birth but no resuscitation (that is, bagging) was needed other than some mask oxygen.

An initial radiograph showed bilateral pneumothoraces (top image).  The outline of the right lung is seen clearly. The left pneumonthorax is more subtle.  The baby had bilateral chest drains inserted and required ventilation.

The second radiograph shows bilateral intercostal drains.  The tip of the left drain is kinked.  The lung fields are not well inflated despite high airway pressures at the time.  This baby has significant pulmonary hypoplasia.

CXR - preterm bilat pneumothoraces.jpg (184214 bytes)

CXR - preterm bilat chest drains.jpg (178564 bytes)

These images are of a preterm infant born at 24 weeks whose ventilation requirements increased on the second day of life.  Transillumination was not diagnostic, perhaps because there was no asymmetry due to the bilateral pneumothoraces.  A chest radiograph demonstrated a large tension pneumothorax on the right side, and a smaller air leak on the left.

Chest drains was inserted and the baby clinically improved.  Note that the right sided drain was inserted too far (note: in small babies, it is all too easy to insert the drains too far).

In a small infant such as this, a head ultrasound scan should be performed to determine whether any deterioration at the time of the pneumothoraces was associated with intraventricular haemorrhage.

Pulmonary Interstitial Emphysema

PIEPneumo.jpg (18188 bytes)

PIE-ICD.jpg (17863 bytes)

Pulmonary interstitial emphysema (PIE) is most commonly seen in small infants with significant RDS.  There are microscopic air leaks, with air tracking along the interstitium of the lung.  Pneumothorax is a common association, and Chronic Lung Disease is also a common sequelae.

The radiographic appearance may be described as "salt and pepper".

If the PIE is localised to one side, the infant can be nursed with that side "down".  Occasionally, selective intubation of the unaffected lung can be performed to "rest" the affected lung.


CXR - Pneumatocoele 1.jpg (156605 bytes) Occasionally, ongoing air leaks occur which result in localised collections of air within the lung parenchyma.   The initial radiograph of this 23 week infant on day one demonstrates a localised area of PIE in the right lower lobe.
CXR - Pneumoatocoele 2.jpg (168930 bytes) The area increased over the next few days, 


...continued to increase in size ...

CXR - Pneumoatocoele 3.jpg (177114 bytes)
CXR - Pneumatocoele 4.jpg (147802 bytes) until it was large enough to compress the right upper lobe and cause mediastinal shift to the left.

Strategies have been proposed to treat this, including selective bronchus intubation to aerate the "good" lung, and there are reports of aggressive surgical resection of the affected lobe.

Last updated Tuesday, 29 November 2011