Traumatic pneumothorax in the newborn

TRAUMATIC PNEUMOTHOI~AX IN THE NEWBORN

JEROME

S. LEOPOLD, M.D., AND FR.EDERICK CASTROVINCI, M.D. N E W YORK, N . Y .

p

N E U M O T H O R A X is of uncommon occurrence in children. Seott 1 in 1928 collected 177 eases in children of various a~,es. In reporting" his own case of pneumothorax, Davies 2 reviewed twenty-seven previously reported. I n 1931 Coccheri and R ossi a reported 300 cases from the literature dating from 1844 to 1980, including sixteen eases of their own.

Stoloff 4 is of the opinion t h a t tuberculosis is p r o b a b l y the most frequent single cause of p n e u m o t h o r a x in children. On the other hand, according" to A n d e r s o n and Cathcart ~ tubereulosis as an etiologic factor i s rare as compared to the 3 per cent occurrence in p u l m o n a r y tuberculosis in adults. However, in considering the nontubereulous causes of p n e u m o t h o r a x in infants and children, Lereboulet and his associates 6 and R oyer de VgrieourU list pneumonia, empyema, lung abscess, and pertussis as the most frequent. Cases of spontaneous p n e u m o t h o r a x either a c c o m p a n y i n g or following pneumonia have been reported by Bashinski, s Lacehia, 9 A e u n a and his eoworkers 1~ and others 11, 12, 13 I n reporting" a ease of p y o p n e u m o t h o r a x from our service, Rogatz and R osenberg *~ found only twelve similar eases in the literature occurring during' the first y e a r of life. Direct t r a u m a to the chest (Maeera and Periss6 *'~) or prolonged difficult deliveries (Donahoe .6) m a y also cause pneumothorax. P i s s a v y and Zimmer .7 report a case of p n e u m o t h o r a x following" p u n c t u r e of the pleura in a fifteen-year-old child, l~uge as in 1878 described the first ease of pneumothorax in the newborn. I n 1930 Stein, .9 in a r e p o r t with a review of the literature, described four cases and added one of his own. Gasul and Singer 2~ b r o u g h t the series up to eight eases. I n an excellent monograph, Glaser and L a n d a u 2~ reported seventeen eases, ineluding one of their own, with a m o r t a l i t y of 47 per cent in pneumot h o r a x in the newborn. Flipse 2" is the only author to report a ease of p n e u m o t h o r a x following hypodermic medieation. The following report of a ease of p n e u m o t h o r a x in the newborn is of interest because we were unable to find in the literature a report of a similar case caused by a t t e m p t e d cardiac puncture. F r o m the A b r a h a m Jaeobl Division for Children of the L e n o x Hill I-Iosloital, New York, Service of Dr. Jerome S. Leopold. 620

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CASE R~POI~T ( C o u r t e s y of Dr. A r t h u r Stein) H. P. H , male, n e w b o r n infant~ was born b y a p r e c i p i t o u s de]ivery on Dec. 2, 1935~ t e n h o u r s a f t e r t h e onset of labor. The b i r t h weight was 5 p o u n d s 8 ~ ounces.

Fig. 1 . - - S h o w i n g a 50 per cent pneumothorax, partial collapse of t h e left lung, and s h i f t i n g of the m e d i a s t i n u m to the right.

]~ig. 2.--Showing

complete

absorption

of the locat.ed.

air, with

the

mediastinum

normally

A t b i r t h the i n f a n t a p p e a r e d v e r y pale, listless, a n d did n o t b r e a t h e . :In a t t e m p t s a t resuseitation~ besides i m m e r s i o n in h o t a n d cold w a t e r tubs~ alternately~ a n d dilatation o f the rectum~ one a m p u l e of m e d i c a t i o n was i n j e c t e d s u p p o s e d l y into t h e h e a r t

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by means of a 24 gauge, 8s inch needle. When a weak cry was heard, the infant was at once placed in an incubator and oxygen was administered continuously. Complete physical examination several hours later revealed the following findings: The infant appeared apathetic and somewhat eyanosed. Stimulation produced a very weak cry. The respirations were rapid and shallow. The skin was pale and dry. The mucous membranes and the extremities were slightly cyanotic. The anterior fontanel was patent, of normal fullness, and admitted two fingers. The neck was normal. On the chest wall, a needle puncture wound was present in the third intercostal space, just to the left of the sternum. On the left side the thorax appeared fuller than on the right. The respiratory excursions were markedly diminished; tactile fremltus was practically absent; percusslon produced a tymp~nitic note. The breath sounds were exaggerated over the entire right side, and were markedly diminished over the left chest. 1~o rhles were heard. The heart sounds were heard best to the right of the sternum. The abdomen was soft. The liver edge was easily palpated just below the right costal margin. The spleen was not felt. The genitals and extremities were negative. A diagnosis of left-sided pneumothorax was made and was confirmed by roentgen ray examination (Fig. 1). During the first thirty~six hours of life, the infant had four stools consisting of meconium and mucus streaked with fresh blood. The blood was explained on the basis of the trauma to the anus produced secondary to the dilatation procedure instituted as a stimulating measure at birth. The infant was kept in the incubator, and oxygen was administered continuously. The physical findings improved daily. I t was noted that the point o2 maximum intensity of the heart sounds was steadily shifting from the right of the sternum to the left. The breath sounds on the left side gradually became normal. On Dec. 9, 1935 (7 days after birth), the physical examination of the chest was entirely normM. Roentgen ray examination (Fig. 2) reveale~d complete disappearance of the pneumothorax. The oxygen was discontinued. The stools had become f r e e of blood, and the infant was taking breast milk w~ith a complementary formula satis factorily. When discharged from the hospital on Dec. ]1, 1935, the infant weighed 5 pounds 61~ ounces. When seen at the age of five months, he weighed 1~1/2 pounds, was 2 5 ~ inches long, and had two teeth. The infant was of normal development and weU nourished. DISCUSSION I n r e v i e w i n g t h e l i t e r a t u r e on p n e u m o t h o r a x ~n t h e n e w b o r n , t h e e x p l a n a t i o n m o s t f r e q u e n t l y a d v a n c e d f o r t h e m e c h a n i s m of p r o d u c t i o n is t h e r u p t u r e of a n a l v e o l u s d u r i n g r e s u s c i t a t i o n c a u s i n g a b r o m c h o p l e u r a l fistula.

F l i p s e 22 f e e l s t h a t f o r c e f u l r e s p i r a t o r y m o v e m e n t s

a t t h e onset of r e s p i r a t i o n in his case w e r e c a u s e d b y a n a p l a s i a of t h e epiglottie cartilage with subsequent collapse o b s t r u c t i n g the glottis. I n S t e i n ' s ~9 case t h e r e w a s a p p a r e n t l y

a permanent

b r o n c h i a l com-

m u n i c a t i o n w i t h t h e p ] e u r a l c a v i t y b e c a u s e a t ~he e n d o f t w o y e a r s no e x p a n s i o n of t h e r i g h t l u n g h a d o c c u r r e d .

I n t h e case p r e s e n t e d

b y G a s u l a n d S i n g e r , 2~ t h e p a t h o g e n e s i s w a s d e s c r i b e d on t h e basis of a s p i r a t i o n of i n f e c t e d m a t e r i a l at b i r t h w i t h t h e p r o d u c t i o n of a localized pneumonitis.

T h i s p r o c e s s , g o i n g o n to ab scess f o r m a t i o n , r u p -

t u r e d a t t h e a g e o f t h r e e weeks, c a u s i n g p y o p n e u m o t h o r a x a u d l e a d i n g to d e a t h in t h r e e d a y s .

I n t h e case r e p o r t e d b y us, it is f e l t t h a t

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air entered the pleural cavity through the needle puncture wound during the first f e w respiratory efforts. With the onset of the respiratory movements and the subsequent production of a negative pressure in t h e pleural cavity, air was most likely sucked in through the puncture wound. This readily explains the rapid clearing up of the pneumothorax within seven days. SUNI IV[AR.u

A case o.f a newborn infant is presented in whom pneumothorax developed apparently secondary to puncture of the ]eft chest. The air was spontaneous]y absorbed within seven days. Complete recovery resulted. II.E~EREN CES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 34. 15. 16. 17. 18. 19. 20. 21. 22.

Scott, A . J . : Tr. Sect. Dis. Child. A. M. A., p. 58, 1928. Davies, Willard J . : M. Times & Long Island M. J. 62: 237, 1934. Coccheri, Pierre; and Rossi, ~,Tittorio: Arch. dl. pat. e din. reed. 11: 46, 1931. Stoloff, E. Gordon: Am. J. Med. Sc. 176: 657, 1928. Anderson, ~Villiam Willis, and Cathcart, Don :F.: g . M . A . Georgia 23: 456, ]934. Y~ereboulet, P., :Lelong, 3~areeI, and Even, 1~.: Nourisson 17: 257, 1929. Royer de V6ricourt, E.: Gaz. m6d. de France, pp. 879, Oct. 15, 1934. Bashinski, ]3enjamin: South. M. J. 22: 52.5, 1929. Lacchia, Paolo: P e d i a t r i a 37: 901, 1929. Acuna, M., ]3ettinotti, S. I., and Va]lino, M . T . : Arch. argent, de pediat. 2: 349~ 1931. Geyman, Milton J., and Clark, Daniel M.: Radiology 23: 622, 1934. 3~cClendon, S . J . : Arch. l~ediat. 48: 511, 1931. Reitter, ,George S.: Am. J. RoentgenoL 31: 770, 1934. Rogatz, J., and Rosenberg, A.: Am. J. Dis. Child. 41: 1104, 1931. Mucera, Jose M., and Periss6, J u a n M.: Semano reed. 39: 2B:1450, 1932. Donahoe, Will E.: Journal-Lancet 52: 699, 1932. Pissavy, A. and Zimmer: J. de m6d. et chir. prat. 98: 443, 1927. tluge, C.: Ztschr. f. Geburtsh. u. Gyni~k. 2: 31, 1878. Stein, Jacob: Am. J. Dis. Child. 40: 89, 1930. Gasul, Benjamin, and Singer, Haz'ry A.: Am. J. Dis. Child. 45: 1050, 1933. Glaser, Jerome, and Landau, Daniel ]3.: Am. J. Dis. Child. 50: 986, 1935. ]Plipse, M. Jay: J. Florida M. A. 14: 403, 1928. 26 EAST 63RD STREET 2 EAST 54TI~ STREET