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Ministry of Health
NZ Government

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Published: 29/11/2011
Pneumothorax Pulmonary I nterstitial Emphysema Pneumatocoele
Pneumothorax
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:
Assisted ventilation (including CPAP)
Respiratory Distress Syndrome
Meconium Aspiration Syndrome
Other Air Leak Syndromes (e.g. Pulmonary interstitial emphysema)
Pulmonary hypoplasia
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).
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.
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.
Air Leak Syndromes http://www.adhb.govt.nz/newborn/teachingresources/radiology/ALS.htm
1 dari 2 4/16/2014 11:00 AM
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 I nterstitial Emphysema
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.
Pneumatocoele
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.
The area increased over the next few
days,

...continued to increase in size ...
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
Air Leak Syndromes http://www.adhb.govt.nz/newborn/teachingresources/radiology/ALS.htm
2 dari 2 4/16/2014 11:00 AM