Spontaneous Pneumothorax In the Newborn

1
Spontaneous PneumothoraxIn the Newborn

• By
• Angela Oliver-Piquette, Carly Jo Amen, Katie
  Kappel,
• Marjerie Malabanan

2
Overview

• During our clinical experience at St.
  Anthonys North, we had the opportunity to see
  many births.
• One of the most exciting was a cesarean
  delivery that presented with an infant who
  developed a spontaneous pneumothorax.
• Though it is rare in infants, a spontaneous
  pneumothorax varies from 0.07-37.5 of all live
  births.
• We would like to take this opportunity to
  share with you what we learned during this
  clinical experience of the newborn with
  spontaneous pneumothorax.

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Pathophysiology/Physiology

• A pneumothorax is a lung disorder in which air in
  the lungs leaks out through a hole or holes in
  the lung tissue into the space between the chest
  wall and the outer tissue of the lungs.
• Air leaks occur when the alveoli become
  over-distended and rupture. Some pneumothorax in
  infants occur spontaneously while others are due
  to meconium aspiration, in which the fetus
  inhales the first stools in utero and air becomes
  trapped causing over-distension.

4
Predisposing Factors

• Prematurity
• Difficult delivery
• Nucal cord
• Vigorous resuscitation
• Mechanical ventilation
• Respiratory distress

5
Impact

• This topic has the potential to have a huge
  impact on neonatal nursing, though it does not
  occur very frequently.
• Knowing the predisposing factors and looking for
  those newborns at risk will ensure they receive
  the best, appropriate care for their condition.
• Newborns suffering from some respiratory distress
  must be watched carefully and incorporate
  frequent chest radiographs if the infants
  condition declines.

6
Impact, conti.

• Additionally, knowing the signs and symptoms of
  newborn respiratory distress, auscultation of
  lung sounds, and assessing chest expansion is
  imperative to the neonatal nurses who may be
  faced with a pneumothorax.
• If nurses are educated about this topic it will
  ensure the best possible outcome for all neonates
  with respiratory distress.

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Signs and Symptoms

• Respiratory distress
• Rapid breathing
• Grunting
• Nostril flaring
• Chest wall retractions

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Signs and Symptoms, conti.

• Sudden, unexplained deterioration in the
  newborns condition
• Decreased breath sounds
• Apnea
• Bradycardia
• Cyanosis
• Increased oxygen requirements

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Late Signs and Symptoms

• Mottled, asymmetric chest expansion
• Decreased arterial blood pressure
• Shock-like appearance
• Shift in the apical cardiac impulse to the side
  opposite the pneumothorax, often with muffled
  heart sounds.
• Higher PCO2 and decreased pH

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Diagnosis

• X-ray examination is the major method for
  definitive diagnosis of pneumothorax.
• Transillumination of the chest can be performed
  for quick evaluation of the pneumothorax, but can
  be unreliable.

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Treatments

• Thoracentesis
• Hollow needle or cannula is inserted into the
  pleural space to release air, allowing the lung
  to reinflate.
• Because pneumothorax is potentially
  life-threatening for a newborn, immediate removal
  of accumulated air by thoracentesis may be
  warranted.
• This procedure carries a risk of damaging
  the lung pleura with needle tracks as the lung
  reinflates.
• Only can be performed by specifically
  trained personnel

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Thoracentesis Procedure
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Treatments, conti.

• Chest Tube
• A chest tube can be inserted into the
  pleural space for complete resolution of the
  pneumothorax.
• This procedure can only be performed by
  specifically trained personnel.

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Additional Treatments

• Hood or vent
• 100 Oxygen

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Implications for Nursing

• The most important nursing function in caring for
  infants susceptible to pneumothorax is close
  vigilance. Be alert for pneumothorax in
• 1. Infants with RDS with or without
  positive pressure ventilation.
• 2. Infants with meconium-stained
  amniotic fluid.
• 3. Infants with radiographic evidence of
  interstitial or lobular emphysema.
• 4. Infants who required resuscitation at
  birth.
• 5. Infants receiving continuous positive
  airway pressure or positive pressure
• ventilation.

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Implications for Nursing, conti.

• Nurses working in areas where potential for this
  complication is high, such as newborn nurseries
  NICUs, should be able to immediately recognize
  s/s of respiratory distress in infants.
• Initial measures such as assessment of
  respiratory status, administration of O2, and
  immediately alerting practitioners of newborns
  status.
• Additionally, nurses must have needle aspiration
  equipment (30-ml syringe, 3-way stopcock, and 23
  to 35 gauge needles) at the bedside for emergency
  use.

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Case Study

• BB, 38 wks gestation, less than one day old.
• LGA, 9lbs 10oz.
• Cesarean section.
• Multipara
• Gestational diabetes.
• S/S nasal flaring, grunting, intercostal
  respirations, central cyanosis.
• O2 saturation consistently below 90 by SaO2
  monitor.

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Treatment

• X-ray confirmation of spontaneous pneumothorax.
• Humidified 100 Oxygen _at_ 10 liters via hood.
• Created a gradient in his lungs so that air
  trapped in the pleural space was absorbed more
  effectively.
• Within 5 to 6 hrs, BB was weaned down from O2
  with SaO2 of above 92. At approximately 8
  hours, hood removed and BB able to maintain above
  95 SaO2 w/no supplemental oxygen.

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References

• Davidson, M.R., London, M.L., Wieland Ladewig,
  P.A. (2008). Maternal-
• newborn nursing womens health across the
  lifespan (8th ed.). New Jersey
• Pearson Prentice Hall.
• Hockenberry, M.J. (2006). Wongs nursing care of
  infants and children. (8th ed.).
• St. Louis Mosby.
• Logan, M.D., Crispin, M.D., Pausa, M.D. (2010).
  Spontaneous pneumothorax
• of the newborn. American College of Chest
  Physicians, 42, 611-614.
• Singh, S.A., Amin, H. (2005). Familial
  spontaneous pneumothorax in
• neonates. Indian Journal of Pediatrics, 72,
  445-447.
• Schneider Childrens Hospital. (n.d.). High Risk
  Neonate. Retrieved from http//www.
• schneiderchildrenshospital.org/peds_html_fixe
  d/peds/hrnewborn/pnethorx.htm.