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Selective left bronchial intubation for the treatment of pulmonary pseudocyst in the very premature infant
Selective Left Bronchial Intubation for the Treatment of Pulmonary Pseudocyst in the Very Premature Infant By Joanna J. Seibert, Kate Dahlrnann, and Donald E. Hill Little Rock, Arkansas 9 Selective intubation of t h e left m a i n s t e m bronchus w a s accomplished successfully to t r e a t a large pseudocyst of interstitial air in the right lung of an 8 9 0 - g p r e m a t u r e infant. T h e t u b e w a s left in place for 3 0 hours. W i t h o u t the use of cutaneous oxygen monitoring to constantly evaluate the o x y g e n a t i o n of the baby and consequently, the c o r r e c t position of t h e tube, this probably could not have been a c c o m plished in such a small infant. I N D E X W O R D S : Interstitial e m p h y s e m a ; pulmonary pseudocyst.
O C U L A T E D I N T E R S T I T I A L AIR can be
L life-threatening in the newborn and if it is bilateral, the prognosis for recovery is poor. However, when interstitial air is unilateral, several treatment modalities have been reported in the pediatric and surgical literature. We report the use of selective left mainstem bronchial intubation in a small premature baby to treat a pulmonary pseudocyst in the right lung. CASE REPORT
A 890-g black male infant of 27 weeks gestation was delivered vaginally and had Apgars of 1/2. The baby was successfully resuscitated and placed on ventilator. The initial radiograph showed a small radiolucent area in the right lung base (Fig. 1) thought to represent interstitial air. On the second day of life, the infant developed a tension pneumothorax and a chest tube was inserted. The loculated air remained in the lung even when it collapsed under tension. The pneumothorax re-accumulated several times and the chest tube was replaced. By the 12th day of life, the chest tube was finally removed, and the patient was weaned to nasal continuous positive airway pressure (CPAP). Over the next several days, however, the cyst gradually increased in size, shifting the heart and mediastinum to the left with subsequent deterioration of blood gases. The patient had to be reintubated and placed on the ventilator (Fig. 2). At this time, he was re-evaluated for possible surgical removal of the right lower lung. However, the decision was reached to attempt selective intubation of the left mainstem bronchus. This was done at the bedside without fluoroscopy following the guide-
From the Department o f Pediatrics & Radiology, University o f Arkansas for Medical Sciences & Arkansas Children's Hospital. Address reprint requests to Joanna J. Seibert, MD, Department o f Radiology, Arkansas Children's Hospital, 804 Wolfe Street, Little Rock, A K 72201. 9 1984 by Grune & Stratton, Inc. 198
Fig. 1. A radiograph taken shortly after resuscitation showing a small area of Ioculated interstitial emphysema in the right base,
lines described by Sivasubramanian, ~ and with the use of continuous cutaneous 02 monitoring. In addition, direct auscultation was helpful in positioning the tube. The placement of the tube was very critical. Any movement of the child produced significant changes in the position of the endotracheal tube. The placement of the tube was monitored by radiographs every four to six hours and by continuous cutaneous 02 monitoring. There was a gradual decrease in the size of the pseudocyst (Fig. 3). Finally, after 30 hours, it disappeared and the tube was removed. The baby was subsequently weaned from the ventilator in five days. There has been no recurrence of the pulmonary pseudocyst and follow-up radiographs show very mild bronchopulmonary dysplasia. DISCUSSION
T h e m e c h a n i s m for p e r s i s t e n t p u l m o n a r y interstitial emphysema and pseudocyst under tension c o m p l i c a t i n g assisted v e n t i l a t i o n has n o t b e e n c o m p l e t e l y e x p l a i n e d . L e o n i d a s et al, proposed t h a t i n t r a l y m p h a t i c air dissection c a u s e s e m p h y s e m a t o u s l y m p h a n g e c t a s i a , w h i c h m a y be r e s p o n s i b l e for t h e fixation o f t h e lung in t h e e m p h y s e m a t o u s s t a t e w h e n t h e r e is l o c u l a t e d i n t e r s t i t i a l air. 1 P l e n a t et al, 2 b e l i e v e t h e pseudocyst to be l o c u l a t e d i n t r a p l e u r a l blebs p r e d o m i n a t e l y l o c a l i z e d in t h e v i s c e r a l p l e u r a of t h e m e d i a s t i n a l f a c e o f t h e lung. V a r i o u s m o d a l i t i e s h a v e b e e n u s e d for t r e a t m e n t of l o c a l i z e d i n t e r s t i t i a l air. T h e i n v o l v e d l u n g has b e e n successfully r e m o v e d surgically. 3'4 Journal of Pediatric Surgery, VoI. 19, No. 2 (April), 1984
PULMONARY PSEUDOCYST
199
Fig. 2. Increasing size of the Ioculated area of interstitial emphysema causing shift of the heart and mediastinum to the left with deterioration of the patient's blood gases clinically.
Robertson has suggested pneumocentesis. 5 Leonidas and associates have observed resolution after instilling isotonic saline hourly, endotracheal suction, vibration, a n d percussion followed by ventilation with 100% inspired oxygen for five to ten minutes. 6 O f course, prolonged localized interstitial air can resolve spontaneously. 7 Brooks et al, 8 first reported the use of selective bronchial i n t u b a t i o n for the t r e a t m e n t of localized p u l m o n a r y emphysema. They described four infants in which the right m a i n s t e m bronchus was selectively i n t u b a t e d for localized pulm o n a r y interstitial e m p h y s e m a on the left. Subsequently, Goodwin, 9 D i c k m a n , j~ a n d Sivasubra-
Fig. 3. Selective intubation of the left bronchus with decrease in size of the pulmonary pseudocyst.
m a n i a n 1~ described techniques for i n t u b a t i o n of the left bronchus in the newborn. M a t h e w et al, t2 have r e c o m m e n d e d obstruction of the right bronchus when the left bronchus could not be intubated. Georgeson has i n t u b a t e d the left m a i n stem bronchus after passing the lens of the smallest straight bronchoscope t h r o u g h the l u m e n of the endotracheal tube. ~3 To our knowledge, this is the smallest premature (890 g) in which selective left bronchial prolonged i n t u b a t i o n has been described. W e emphasize the successful use of continuous cutaneous oxygen m o n i t o r i n g for correct p l a c e m e n t of the endotracheal tube.
REFERENCES
1. Leonidas JC, Bhan I, McCauley RG: Persistent localized pulmonary interstitial emphysema and lymphangiectasia: A causal relationship? Pediatrics 64:165-171, 1979 2. Plenat F, Vert P, Didier F, et al: Pulmonary interstitial emphysema. Clin Perinatol 5:351-375, 1978 3. Bauer CR, Brennan MJ, Doyle C, et al: Surgical resection for pulmonary interstitial emphysema in the newborn infant. J Pediatr 93:656-661, 1978 4. Reyes HM, Kagan RJ, Rowlatt UF, et al: Pulmonary interstitial emphysema~urgical management: Report of three cases. J Pediatr Surg 15:266-269, 1980 5. Robertson NRC: Treatment of cystic ventilator lung disease. Proc R Soc Med 69:344-345, 1976 6. Leonidas JC, Hall RT, Rhodes PG: Conservativemanagement of unilateral pulmonary interstitial emphysema under tension. J Pediatr 87:776 778, 1975 7. Lopez JB: Nonoperative resolution of prolonged localized intrapulmonary interstitial emphysema associated with hyaline membrane disease. J Podiatr 91:653-654, 1977
8. Brooks JG, Bustamante SA, Koops BL, et al: Selective bronchial intubation for the treatment of severe localized pulmonary interstitial emphysema in newborn infants. J Pediatr 91:648-652, 1977 9. Goodwin CC: More on intubation of left main stem bronchus. J Pediatr 92:1029, 1978 10. Dickman GL: Selective bronchial intubation for treatment of localized pulmonary emphysema. J Pediatr 92:860, 1978 11. Sivasubramanian KN: Technique of selective intubation of the left bronchus in newborninfants. J Pediatr 94:479, 1979 12. Mathew OP, Thach BT: Selective bronchial obstruction for treatment of bullous interstitial emphysema. J Pediatr 96:475-477, 1980 13. Georgeson KE, Vain NE: Intubation of the left main stem bronchus in newborn infants: A new technique. J Pediatr 96:920-921, 1981
O C U L A T E D I N T E R S T I T I A L AIR can be
L life-threatening in the newborn and if it is bilateral, the prognosis for recovery is poor. However, when interstitial air is unilateral, several treatment modalities have been reported in the pediatric and surgical literature. We report the use of selective left mainstem bronchial intubation in a small premature baby to treat a pulmonary pseudocyst in the right lung. CASE REPORT
A 890-g black male infant of 27 weeks gestation was delivered vaginally and had Apgars of 1/2. The baby was successfully resuscitated and placed on ventilator. The initial radiograph showed a small radiolucent area in the right lung base (Fig. 1) thought to represent interstitial air. On the second day of life, the infant developed a tension pneumothorax and a chest tube was inserted. The loculated air remained in the lung even when it collapsed under tension. The pneumothorax re-accumulated several times and the chest tube was replaced. By the 12th day of life, the chest tube was finally removed, and the patient was weaned to nasal continuous positive airway pressure (CPAP). Over the next several days, however, the cyst gradually increased in size, shifting the heart and mediastinum to the left with subsequent deterioration of blood gases. The patient had to be reintubated and placed on the ventilator (Fig. 2). At this time, he was re-evaluated for possible surgical removal of the right lower lung. However, the decision was reached to attempt selective intubation of the left mainstem bronchus. This was done at the bedside without fluoroscopy following the guide-
From the Department o f Pediatrics & Radiology, University o f Arkansas for Medical Sciences & Arkansas Children's Hospital. Address reprint requests to Joanna J. Seibert, MD, Department o f Radiology, Arkansas Children's Hospital, 804 Wolfe Street, Little Rock, A K 72201. 9 1984 by Grune & Stratton, Inc. 198
Fig. 1. A radiograph taken shortly after resuscitation showing a small area of Ioculated interstitial emphysema in the right base,
lines described by Sivasubramanian, ~ and with the use of continuous cutaneous 02 monitoring. In addition, direct auscultation was helpful in positioning the tube. The placement of the tube was very critical. Any movement of the child produced significant changes in the position of the endotracheal tube. The placement of the tube was monitored by radiographs every four to six hours and by continuous cutaneous 02 monitoring. There was a gradual decrease in the size of the pseudocyst (Fig. 3). Finally, after 30 hours, it disappeared and the tube was removed. The baby was subsequently weaned from the ventilator in five days. There has been no recurrence of the pulmonary pseudocyst and follow-up radiographs show very mild bronchopulmonary dysplasia. DISCUSSION
T h e m e c h a n i s m for p e r s i s t e n t p u l m o n a r y interstitial emphysema and pseudocyst under tension c o m p l i c a t i n g assisted v e n t i l a t i o n has n o t b e e n c o m p l e t e l y e x p l a i n e d . L e o n i d a s et al, proposed t h a t i n t r a l y m p h a t i c air dissection c a u s e s e m p h y s e m a t o u s l y m p h a n g e c t a s i a , w h i c h m a y be r e s p o n s i b l e for t h e fixation o f t h e lung in t h e e m p h y s e m a t o u s s t a t e w h e n t h e r e is l o c u l a t e d i n t e r s t i t i a l air. 1 P l e n a t et al, 2 b e l i e v e t h e pseudocyst to be l o c u l a t e d i n t r a p l e u r a l blebs p r e d o m i n a t e l y l o c a l i z e d in t h e v i s c e r a l p l e u r a of t h e m e d i a s t i n a l f a c e o f t h e lung. V a r i o u s m o d a l i t i e s h a v e b e e n u s e d for t r e a t m e n t of l o c a l i z e d i n t e r s t i t i a l air. T h e i n v o l v e d l u n g has b e e n successfully r e m o v e d surgically. 3'4 Journal of Pediatric Surgery, VoI. 19, No. 2 (April), 1984
PULMONARY PSEUDOCYST
199
Fig. 2. Increasing size of the Ioculated area of interstitial emphysema causing shift of the heart and mediastinum to the left with deterioration of the patient's blood gases clinically.
Robertson has suggested pneumocentesis. 5 Leonidas and associates have observed resolution after instilling isotonic saline hourly, endotracheal suction, vibration, a n d percussion followed by ventilation with 100% inspired oxygen for five to ten minutes. 6 O f course, prolonged localized interstitial air can resolve spontaneously. 7 Brooks et al, 8 first reported the use of selective bronchial i n t u b a t i o n for the t r e a t m e n t of localized p u l m o n a r y emphysema. They described four infants in which the right m a i n s t e m bronchus was selectively i n t u b a t e d for localized pulm o n a r y interstitial e m p h y s e m a on the left. Subsequently, Goodwin, 9 D i c k m a n , j~ a n d Sivasubra-
Fig. 3. Selective intubation of the left bronchus with decrease in size of the pulmonary pseudocyst.
m a n i a n 1~ described techniques for i n t u b a t i o n of the left bronchus in the newborn. M a t h e w et al, t2 have r e c o m m e n d e d obstruction of the right bronchus when the left bronchus could not be intubated. Georgeson has i n t u b a t e d the left m a i n stem bronchus after passing the lens of the smallest straight bronchoscope t h r o u g h the l u m e n of the endotracheal tube. ~3 To our knowledge, this is the smallest premature (890 g) in which selective left bronchial prolonged i n t u b a t i o n has been described. W e emphasize the successful use of continuous cutaneous oxygen m o n i t o r i n g for correct p l a c e m e n t of the endotracheal tube.
REFERENCES
1. Leonidas JC, Bhan I, McCauley RG: Persistent localized pulmonary interstitial emphysema and lymphangiectasia: A causal relationship? Pediatrics 64:165-171, 1979 2. Plenat F, Vert P, Didier F, et al: Pulmonary interstitial emphysema. Clin Perinatol 5:351-375, 1978 3. Bauer CR, Brennan MJ, Doyle C, et al: Surgical resection for pulmonary interstitial emphysema in the newborn infant. J Pediatr 93:656-661, 1978 4. Reyes HM, Kagan RJ, Rowlatt UF, et al: Pulmonary interstitial emphysema~urgical management: Report of three cases. J Pediatr Surg 15:266-269, 1980 5. Robertson NRC: Treatment of cystic ventilator lung disease. Proc R Soc Med 69:344-345, 1976 6. Leonidas JC, Hall RT, Rhodes PG: Conservativemanagement of unilateral pulmonary interstitial emphysema under tension. J Pediatr 87:776 778, 1975 7. Lopez JB: Nonoperative resolution of prolonged localized intrapulmonary interstitial emphysema associated with hyaline membrane disease. J Podiatr 91:653-654, 1977
8. Brooks JG, Bustamante SA, Koops BL, et al: Selective bronchial intubation for the treatment of severe localized pulmonary interstitial emphysema in newborn infants. J Pediatr 91:648-652, 1977 9. Goodwin CC: More on intubation of left main stem bronchus. J Pediatr 92:1029, 1978 10. Dickman GL: Selective bronchial intubation for treatment of localized pulmonary emphysema. J Pediatr 92:860, 1978 11. Sivasubramanian KN: Technique of selective intubation of the left bronchus in newborninfants. J Pediatr 94:479, 1979 12. Mathew OP, Thach BT: Selective bronchial obstruction for treatment of bullous interstitial emphysema. J Pediatr 96:475-477, 1980 13. Georgeson KE, Vain NE: Intubation of the left main stem bronchus in newborn infants: A new technique. J Pediatr 96:920-921, 1981