Case ReportTension Pneumatocele

Feb. 4th, 2005

R1 Su, H.C.

MaleG3P3

C/S at 30 wksFeb. 19th, 2004

1640 gm7.6 kg

1st Admission: Ward

•High fever•Respiratory failure

•CT arranged

Sudden onset of severe tachypnea on Jan. 9th, 2005

Physical Examination

Jugular veins

Breath sounds

Heart sounds

2 Days Passed

Dyspnea

Progressive subcutaneous emphysema

Multiple Smaller Ones

Compressed pulmonary parenchymaCompressed pulmonary parenchyma

Recurrence !

It’s Tension Pneumatocele !

NimbexNimbexNimbexNimbex

SCCSCCSCCSCC

IsofluraneIsofluraneIsofluraneIsoflurane

KetaminKetaminKetaminKetamin

Induction,Induction,keep spontaneous keep spontaneous

ventilation.ventilation.

Induction,Induction,keep spontaneous keep spontaneous

ventilation.ventilation.

Failed intubation x 2Failed intubation x 2Failed intubation x 2Failed intubation x 2

Catheters insertedCatheters insertedCatheters insertedCatheters inserted

Failed intubation x 1Failed intubation x 1Failed intubation x 1Failed intubation x 1

Laryngospasm,Laryngospasm,SpOSpO22 droped to 60%. droped to 60%.

Laryngospasm,Laryngospasm,SpOSpO22 droped to 60%. droped to 60%.

Paralyzed,Paralyzed,SpOSpO22 returned to 80%. returned to 80%.

Paralyzed,Paralyzed,SpOSpO22 returned to 80%. returned to 80%.

SpOSpO22 > 90%, > 90%,Surgery proceeded.Surgery proceeded.

SpOSpO22 > 90%, > 90%,Surgery proceeded.Surgery proceeded.

What Happened During Induction ?What Happened

During Induction ?

About the Surgery

Left decubitus position

Posterolateral thoracotomy

Bullaes

LLL lobectomy

PneumatocelePneumatocele

NecrotizingPneumoniaNecrotizingPneumonia

Necrotizing Pneumonia

Invasive pneumonia + necrotic foci

Abscess

Bronchopulmonary fistula

Parapneumonic effusion

Rare in childhood

Synonyms: pulmonary gangrene

Surgery is often required

Thin-walled, gas-filled cysts

Sequela of pneumonia

1 week to 6 weeks

Check-valve

Antibiotic

Pneumatocele

Complications of Pneumatocele

Tension pneumatocele

Pneumothorax

Secondarily infected pneumatocele

Bullae?Pneumatocele ?

What Can We Do in Tension Pneumatocele ?

Outlines

Algorithm

Early Intervention

Operative Treatment

A 1m/o, markedly hypoxic, high risk for open surgery management

Under fluoroscopic guidance

Guidewire through an 18-gauge needle into the pneumatocele; dilatation of the tract followed.

5-Fr pigtail catheter inserted with Pleur-Evac

Decompression of pneumatocele in a neonate by percutaneous catheter placement (Case Reports)

Kogutt et al. Pediatr Radiol 29: 488-489, 1999

Management of Tension Pneumatocele With High-Frequency Oscillatory Ventilation (Case Reports)

Hsiu-Nien Shen et al. Chest 121: 284-286, 2002

3 y/o girl with pneumonia, intubated with CMV

Massive air leak via chest tube + persistence of poor oxygenation

CMV may predispose her to enlarging pneumatocele and airleak

HFOV initiated

Condition improved

Treatment of pneumothorax in newborns: Use of venous catheter versus chest tube

Arda et al. Pediatr Int 44: 78-82, 2002

72 newborn patients divided into 2 groups

Chest tube versus 18-gauge catheter

Shorter duration of the procedure

Lower complication rate

A safe alternative, particularly useful for newborn

What Do We Learn From This Case?

Tension Pneumatoceles, Multiple

Unsatisfactory Oxygenation

Blind Insertion of Multiple Catheters

Little Risk of Myocardium Stab

Life-saving Technique

Necrotizing Pneumonia in Children. Hacimustafaoglu et al. Acta paediatr 93: 1172-1177, 2004Management of Complicated Pneumatocele. DiBardino et al. J Thorac Cardiovasc Surg 126: 859-861, 2003Decompression of Pneumatocele in a Neonate by Percutaneous Catheter Placement. Kogutt et al. Pediatr Radiol 29: 488-489, 1999Management of Tension Pneumatocele With High-Frequency Oscillatory Ventilation. Hsiu-Nien Shen et al. Chest 121: 284-286, 2002Treatment of Pneumothorax in Newborns: Use of Venous Catheter versus Chest Tube. Arda et al. Pediatr Int 44: 78-82, 2002

Thanks for your attention

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