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Selective bronchial obstruction for treatment of bullous interstitial emphysema
Volume 96 Number 3, part 1 REFERENCES 1. Sell E, editor: Follow-up of the high-risk newborn-a practical approach, Springfield, I11, Charles C Thomas, Publisher (in press). 2. O'Doherty N: Atlas of the newborn, Philadelphia, 1979, JB Lippincott Company, p 166. 3. Lever WF, and Schaumberg-Lever G: Histopathology of the skin, ed 5, Philadelphia, 1975, J.B. Lippincott Company. 4. Shapiro L, Platt N, and Torres-Rodriquez VM: Idiopathic calcinosis of the scrotum, Arch Dermatol 102:199, 1970.
Brief clinical and laboratory observations
475
5. Pinkus H: Epidermoid cysts or epidermal inclusion cysts, Arch Dermatol 111:130, 1975. 6. Winer LH: Solitary congenital calcification of the skin, Arch Dermatol 66:204, 1952. 7. Schumes E, and Wood MG: Subepidermal calcified nodulesl Arch Dermatol 105:593, 1972. 8. Cornelius CE, Tenenhous AT, and Weber, JC: Calcinosis cutis: metabolic, histochemical, X-ray diffraction, and electronmicroscopic study, Arch Dermatol 98:219, 1968. 9. Woods B, and Kellaway TB: Cutaneous calculi: subepiderreal calcified nodules, Br J Dermatol 75:1, 1963.
Selective bronchial obstruction for treatment of bullous interstitial emphysema Oommen P. Mathew, M.D.,* and Bradley T. Thach, M.D., St. Louis, Mo.
PULMONARY I N T E R S T I T I A L EMPHYSEMA is a k n o w n complication o f hyaline m e m b r a n e disease requiring ventilatory assistance?. 2 In rare cases it leads to the f o r m a t i o n of bullae with massive inflation o f one or more lobes, causing m e d i a s t i n a l shift a n d compression o f the contralateral lung. Various modalities o f treatment, such as selective b r o n c h i a l i n t u b a t i o n ~, ~ a n d surgical resection?. 0 h a v e b e e n reported to be successful. W e report a n i n f a n t with severe PIE and collapse o f the contralateral lung who was treated by selective obstruction o f a m a j o r bronchus. CASE REPORT This 950 gram, 29-week gestational age twin A infant was born by vertex vaginal delivery with Apgar scores of 4 and 5 at one and five minutes, respectively. He required mechanical ventilation for severe HMD; PIE was noted on the chest radiograph on day two. The clinical course was complicated by the development of patent ductus arteriosus with heart failure. PIE gradually worsened on the right side with hyperexpansion, herniation across the midline, and compression of the left lung. On day 11 the infant was transferred to St. Louis Children's Hospital. On admission the infant was being treated with high concentrations of inspired oxygen, high peak inspiratory pressure, and PEEP. Chest radiograph revealed extensive PIE and bullae in the right lung with mediastitial shift and collapse of the left lung and right upper lobe (Fig. 1). Attempts to improve ventilation in the From the Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, and the Division of Neonatology, St. Louis Children's Hospital. *Reprint address: Department of Pediatrics. St. Louis Children's"Hospital, 500 South Kingshighway, P.O. Box 14871, St. Louis, MO 63178.
0022-3476/80/030475 + 03500.30/0 9 1980 The C. V. Mosby Co.
left lung by altering respiratory pressure settings were unsuccessful. On day 13, the patient was transported to the radiology procedure room for selective intubation of the left mainstem bronchus under fluoroscopy. This was accomplished with great difficulty and the patient developed severe bradycardia, cyanosis, and hypothermia. Following the procedure the patient failed to improve and developed severe acidosis and hypercarbia. Because of the concern that the endotracheal tube might be obstructing the left upper lobe bronchus, the tube was withdrawn from the left mainstem bronchus after two hours. Over the next week the infant's clinical conditions steadily deteriorated. This prompted another trial of left mainstem intubation, but his unstable clinical status no longer permitted transfer to the radiology department. Blind intubation of the left mainstem bronchus was attempted in the nursery but was unsuccessful; he developed severe hypoxia, acidosis, hypercarbia, and bradycardia, necessitating resuscitation. A right pneumothorax, which developed during this procedure, was treated with a chest tube. Abbreviations used PIE: pulmonary interstitial emphysema HMD: hyaline membrane disease PEEP: positive end-expiratory pressure BPM: breaths per minute After obtaining informed parental consent, right m a i n s t e m obstruction was performed on day 23. An endotracheal tube adaptor with side holes (Novametrix Med. Systems, Wallington, Conn.; C/D suction adaptor) for suctioning was connected to the respirator. A handmade latex esophageal pressure balloon 7 was cut to reduce length and was reattached to a soft Argyle 3.5 F umbilical catheter; it measured 1.25 cm in length and 1.0 cm in width when fully inflated. The distance the balloon was to be advanced through the side hole of the endotracheai tube adaptor was calculated by adding the distance measured from the tip of
4 76
Brief clinical and laborator/observations
The Journal of Pediatrics March 1980
place for 48 hours, at which time it was deflated without changing its position. Accidental dislodgement of the balloon into the trachea occurred three hours after deflation. Because of reappearance of early bullous lesions, the balloon-tipped catheter was reinserted as described previously; the procedure was well tolerated by the infant. After 72 hours, the balloon-tipped catheter was removed without reaccumulation of the bullae. In the period following the initial collapse of the bullae, we were able to wean the infant from the high respiratory settings (1.0 FI%, 50 BPM, 8 cm H_~OPEEP, and 30 cm H~O peak air-pressure to 0.40 FI%, 15 BPM, 2 cm H~O PEEP and 16 cm peak air-pressure). Unfortunately, over the next four weeks the infant developed renal failure of undetermined etiology and died. Request for postmortem examination was denied by the parents. COMMENTS Fig. 1. Pulmonary interstitial emphysema of right middle and lower lobes under tension with collapse of left lung and right upper lobe prior to selective obstruction.
Fig. 2. The inflated balloon selectively obstructs the right middle and lower lobe bronchi. Collapse of the right middle and lower lobes, re-expansion of left lung and right upper lobe, and right chest tube are also seen. the endotracheal tube to the desired position in the mainstem bronchus, to the length of the endotracheal tube. The balloontipped catheter was inserted and, after confirming the position .by radiograph, a predetermined volume of air (0.7 ml) was injected through a three-way stopcock attached to the catheter. Insertion of the tube and inflation of the balloon was accomplished without any discernible change in the infant's clinical condition. Marked improvement in arterial blood gas values was seen within two hours of inflation (pH 7.25, Pco, 82 torr, and Po~ 39 torr vs pH 7.58, Pco~ 37 torr, and Po_~ 75 torr). Progressive re-expansion of the left lung and right upper lobe with collapse of right middle and lower lobes were seen on follow-up radiographs (Fig. 2). Periodic endoctracheal tube lavage and suctioning were performed using a 3.5 French catheter. The balloon was left in
Conservative management s. s and selective bronchial intubation have been reported to be successful in some infants with PIE. However, our patient did not improve with conservative measures and tolerated the left mainstem intubation very poorly. Because of the infant's extremely poor condition, we did not consider surgery. However, we were able to perform selective right mainstem obstruction easily and in so doing were able to restore ventilation not only to the left lung, but also to the right upper lobe. The infant tolerated the procedure well. The theoretical risks involved in this procedure are difficulty suctioning, accidental dislodgement, infection, ball valve effect leading to further air trapping, and pressure necrosis. The balloon used was very compliant and we believe the amount of pressure required to inflate it (1 to 2 cm H~O) probably reduced the likelihood of pressure necrosis. No evidence of ball valve effect was observed on follow-up radiographs, indicating that high pressure in the balloon is not required for sealing off the bronchus. Accidental dislodgement was the only complication we experienced. Suctioning could be performed using a 3.5 F catheter. Bacterial infection was not encountered. Our experience supports the previous observation that optimal duration of selective intubation or obstruction is three to five days. We believe that selective obstruction of the mainstem bronchus is a desirable alternative to previously described therapies, especially if the lesion is right sided. Its advantages over selective intubation are that it can be performed easily without fluoroscopy and it does not require reintubation or disconnection of the infant from the respirator. Additionally, if the middle or lower lobes are primarily involved, they may be selectively obstructed, retaining ventilation to the upper lobe of the affected side.
Volume 96 Number 3, part 1 REFERENCES
1. Thibeault DW, Lachman RS, Laul VR, and Kwong MS: Pulmonary interstitial emphysema, pneumomediastinum and pneumothorax, Am J Dis Child 126:611, 1973. 2, Campbell RE: Intrapulmonary interstitial emphysema. A complication of hyaline membrane disease, Am J Roetgenol Rad Ther Nucl Med 110:449, 1970. 3. Brooks JG, Bustamante SA, Koops BL, Hilton S, Cooper D, Wesenberg GL, and Simons MA: Selective bronchial intubation for treatment of severe localized pulmonary interstitial emphysema in newborn infants, J P~DIATR 91:648, 1977. 4. Dickman GL, Short BL, and Krauss DR: Selective bronchial intubation in the management of unilateral pulmonary interstitial emphysema, Am J Dis Child 131:365, 1977.
Brief clinical and laboratory observations
477
5. Fletcher BD, Outerbridge EW, Youssef S, and Bolande RP: Pulmonary interstitial emphysema in a newborn infant treated by lobectomy, Pediatrics 54:808, 1974. 6. Magilner AD, Capitanio MA, Wertheimer 1, and Burko H: Persistent localized intrapulmonary interstitial emphysema. An observation in three infants, Radiology 111:379, 1974. 7. Mead J, Mcllroy MB, Silvertone NJ, and Kriete BC: Measurement of intraesophageal pressure, J Appl Physiol 7:491, 1955. 8. Leonidas JC, Hall RT, and Rhodes PG: Conservative management of unilateral pulmonary interstitial emphysema under tension, J PEDIATR 87:776, 1975. 9. Lopez JB, Campbell RE, Bishop HC, and Boggs TR: Nonoperative resolution of prolonged localized intrapulmonary interstitial emphysema associated with hyaline membrane disease, J PEDIATR 91:653, 1977.
Brief clinical and laboratory observations
475
5. Pinkus H: Epidermoid cysts or epidermal inclusion cysts, Arch Dermatol 111:130, 1975. 6. Winer LH: Solitary congenital calcification of the skin, Arch Dermatol 66:204, 1952. 7. Schumes E, and Wood MG: Subepidermal calcified nodulesl Arch Dermatol 105:593, 1972. 8. Cornelius CE, Tenenhous AT, and Weber, JC: Calcinosis cutis: metabolic, histochemical, X-ray diffraction, and electronmicroscopic study, Arch Dermatol 98:219, 1968. 9. Woods B, and Kellaway TB: Cutaneous calculi: subepiderreal calcified nodules, Br J Dermatol 75:1, 1963.
Selective bronchial obstruction for treatment of bullous interstitial emphysema Oommen P. Mathew, M.D.,* and Bradley T. Thach, M.D., St. Louis, Mo.
PULMONARY I N T E R S T I T I A L EMPHYSEMA is a k n o w n complication o f hyaline m e m b r a n e disease requiring ventilatory assistance?. 2 In rare cases it leads to the f o r m a t i o n of bullae with massive inflation o f one or more lobes, causing m e d i a s t i n a l shift a n d compression o f the contralateral lung. Various modalities o f treatment, such as selective b r o n c h i a l i n t u b a t i o n ~, ~ a n d surgical resection?. 0 h a v e b e e n reported to be successful. W e report a n i n f a n t with severe PIE and collapse o f the contralateral lung who was treated by selective obstruction o f a m a j o r bronchus. CASE REPORT This 950 gram, 29-week gestational age twin A infant was born by vertex vaginal delivery with Apgar scores of 4 and 5 at one and five minutes, respectively. He required mechanical ventilation for severe HMD; PIE was noted on the chest radiograph on day two. The clinical course was complicated by the development of patent ductus arteriosus with heart failure. PIE gradually worsened on the right side with hyperexpansion, herniation across the midline, and compression of the left lung. On day 11 the infant was transferred to St. Louis Children's Hospital. On admission the infant was being treated with high concentrations of inspired oxygen, high peak inspiratory pressure, and PEEP. Chest radiograph revealed extensive PIE and bullae in the right lung with mediastitial shift and collapse of the left lung and right upper lobe (Fig. 1). Attempts to improve ventilation in the From the Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, and the Division of Neonatology, St. Louis Children's Hospital. *Reprint address: Department of Pediatrics. St. Louis Children's"Hospital, 500 South Kingshighway, P.O. Box 14871, St. Louis, MO 63178.
0022-3476/80/030475 + 03500.30/0 9 1980 The C. V. Mosby Co.
left lung by altering respiratory pressure settings were unsuccessful. On day 13, the patient was transported to the radiology procedure room for selective intubation of the left mainstem bronchus under fluoroscopy. This was accomplished with great difficulty and the patient developed severe bradycardia, cyanosis, and hypothermia. Following the procedure the patient failed to improve and developed severe acidosis and hypercarbia. Because of the concern that the endotracheal tube might be obstructing the left upper lobe bronchus, the tube was withdrawn from the left mainstem bronchus after two hours. Over the next week the infant's clinical conditions steadily deteriorated. This prompted another trial of left mainstem intubation, but his unstable clinical status no longer permitted transfer to the radiology department. Blind intubation of the left mainstem bronchus was attempted in the nursery but was unsuccessful; he developed severe hypoxia, acidosis, hypercarbia, and bradycardia, necessitating resuscitation. A right pneumothorax, which developed during this procedure, was treated with a chest tube. Abbreviations used PIE: pulmonary interstitial emphysema HMD: hyaline membrane disease PEEP: positive end-expiratory pressure BPM: breaths per minute After obtaining informed parental consent, right m a i n s t e m obstruction was performed on day 23. An endotracheal tube adaptor with side holes (Novametrix Med. Systems, Wallington, Conn.; C/D suction adaptor) for suctioning was connected to the respirator. A handmade latex esophageal pressure balloon 7 was cut to reduce length and was reattached to a soft Argyle 3.5 F umbilical catheter; it measured 1.25 cm in length and 1.0 cm in width when fully inflated. The distance the balloon was to be advanced through the side hole of the endotracheai tube adaptor was calculated by adding the distance measured from the tip of
4 76
Brief clinical and laborator/observations
The Journal of Pediatrics March 1980
place for 48 hours, at which time it was deflated without changing its position. Accidental dislodgement of the balloon into the trachea occurred three hours after deflation. Because of reappearance of early bullous lesions, the balloon-tipped catheter was reinserted as described previously; the procedure was well tolerated by the infant. After 72 hours, the balloon-tipped catheter was removed without reaccumulation of the bullae. In the period following the initial collapse of the bullae, we were able to wean the infant from the high respiratory settings (1.0 FI%, 50 BPM, 8 cm H_~OPEEP, and 30 cm H~O peak air-pressure to 0.40 FI%, 15 BPM, 2 cm H~O PEEP and 16 cm peak air-pressure). Unfortunately, over the next four weeks the infant developed renal failure of undetermined etiology and died. Request for postmortem examination was denied by the parents. COMMENTS Fig. 1. Pulmonary interstitial emphysema of right middle and lower lobes under tension with collapse of left lung and right upper lobe prior to selective obstruction.
Fig. 2. The inflated balloon selectively obstructs the right middle and lower lobe bronchi. Collapse of the right middle and lower lobes, re-expansion of left lung and right upper lobe, and right chest tube are also seen. the endotracheal tube to the desired position in the mainstem bronchus, to the length of the endotracheal tube. The balloontipped catheter was inserted and, after confirming the position .by radiograph, a predetermined volume of air (0.7 ml) was injected through a three-way stopcock attached to the catheter. Insertion of the tube and inflation of the balloon was accomplished without any discernible change in the infant's clinical condition. Marked improvement in arterial blood gas values was seen within two hours of inflation (pH 7.25, Pco, 82 torr, and Po~ 39 torr vs pH 7.58, Pco~ 37 torr, and Po_~ 75 torr). Progressive re-expansion of the left lung and right upper lobe with collapse of right middle and lower lobes were seen on follow-up radiographs (Fig. 2). Periodic endoctracheal tube lavage and suctioning were performed using a 3.5 French catheter. The balloon was left in
Conservative management s. s and selective bronchial intubation have been reported to be successful in some infants with PIE. However, our patient did not improve with conservative measures and tolerated the left mainstem intubation very poorly. Because of the infant's extremely poor condition, we did not consider surgery. However, we were able to perform selective right mainstem obstruction easily and in so doing were able to restore ventilation not only to the left lung, but also to the right upper lobe. The infant tolerated the procedure well. The theoretical risks involved in this procedure are difficulty suctioning, accidental dislodgement, infection, ball valve effect leading to further air trapping, and pressure necrosis. The balloon used was very compliant and we believe the amount of pressure required to inflate it (1 to 2 cm H~O) probably reduced the likelihood of pressure necrosis. No evidence of ball valve effect was observed on follow-up radiographs, indicating that high pressure in the balloon is not required for sealing off the bronchus. Accidental dislodgement was the only complication we experienced. Suctioning could be performed using a 3.5 F catheter. Bacterial infection was not encountered. Our experience supports the previous observation that optimal duration of selective intubation or obstruction is three to five days. We believe that selective obstruction of the mainstem bronchus is a desirable alternative to previously described therapies, especially if the lesion is right sided. Its advantages over selective intubation are that it can be performed easily without fluoroscopy and it does not require reintubation or disconnection of the infant from the respirator. Additionally, if the middle or lower lobes are primarily involved, they may be selectively obstructed, retaining ventilation to the upper lobe of the affected side.
Volume 96 Number 3, part 1 REFERENCES
1. Thibeault DW, Lachman RS, Laul VR, and Kwong MS: Pulmonary interstitial emphysema, pneumomediastinum and pneumothorax, Am J Dis Child 126:611, 1973. 2, Campbell RE: Intrapulmonary interstitial emphysema. A complication of hyaline membrane disease, Am J Roetgenol Rad Ther Nucl Med 110:449, 1970. 3. Brooks JG, Bustamante SA, Koops BL, Hilton S, Cooper D, Wesenberg GL, and Simons MA: Selective bronchial intubation for treatment of severe localized pulmonary interstitial emphysema in newborn infants, J P~DIATR 91:648, 1977. 4. Dickman GL, Short BL, and Krauss DR: Selective bronchial intubation in the management of unilateral pulmonary interstitial emphysema, Am J Dis Child 131:365, 1977.
Brief clinical and laboratory observations
477
5. Fletcher BD, Outerbridge EW, Youssef S, and Bolande RP: Pulmonary interstitial emphysema in a newborn infant treated by lobectomy, Pediatrics 54:808, 1974. 6. Magilner AD, Capitanio MA, Wertheimer 1, and Burko H: Persistent localized intrapulmonary interstitial emphysema. An observation in three infants, Radiology 111:379, 1974. 7. Mead J, Mcllroy MB, Silvertone NJ, and Kriete BC: Measurement of intraesophageal pressure, J Appl Physiol 7:491, 1955. 8. Leonidas JC, Hall RT, and Rhodes PG: Conservative management of unilateral pulmonary interstitial emphysema under tension, J PEDIATR 87:776, 1975. 9. Lopez JB, Campbell RE, Bishop HC, and Boggs TR: Nonoperative resolution of prolonged localized intrapulmonary interstitial emphysema associated with hyaline membrane disease, J PEDIATR 91:653, 1977.