Less Invasive Management of a Large Pneumatocele

By Heidi Morris, MMS, PA-C, Physician Assistant and Research Coordinator, Division of Neonatology

In this article, we review a case of a preterm infant with severe bronchopulmonary dysplasia (BPD), a history of S. aureus pneumonia, and subsequent large pneumatocele, managed with a less typical treatment modality.

RC was born preterm at 25 weeks gestation and spent the first three months of life at a community NICU. In addition to typical issues related to extreme prematurity, RC acquired Staphylococcus aureus sepsis and pneumonia, on DOL 12. Subsequently, her course was complicated by bilateral pneumatoceles. She required invasive mechanical ventilation for the majority of her hospital course and failed three attempts at extubation, despite two courses of lung-targeted steroids. RC had an acute worsening in respiratory status associated with an increasing right-sided pneumatocele and pneumothorax.

CHOP’s Surgeon-in-Chief, N. Scott Adzick, MD, reviewed RC’s case and recommended transfer to CHOP for potential surgical resection. At just over 40 weeks post-menstrual age, RC was admitted to CHOP’s Newborn/Infant Chronic Lung Disease Program (NeoCLD) for management of her pneumatocele and severe BPD. She was noted to have chronic hypercarbia and acutely progressive hypoxia; on plain film, a large right pneumatocele with mediastinal shift and compression of bilateral lung tissue was noted. In conjunction with General Surgery, the decision was made to proceed with surgery.

While in the operating room, Dr. Adzick noted an “orangesized” pneumatocele. He had originally planned for a right upper lobectomy, but he became concerned for both the complexity of the surgery as well as the infant’s potential intolerance to invasive surgery, given her high PCO2 values and oxygen needs, particularly if she was to have an uncontrolled air leak. Thus, the decision was made to perform an indwelling anterior right tube thoracostomy (into the pneumatocele) to allow for continued evacuation. The initial intention was to provide decompression of the pneumatocele in order to restore lung volumes and architecture and provide clinical stability for a potential staged surgery.

Immediately following surgery there was near complete resolution of pneumatocele on film. Clinically, RC had a dramatic improvement in ventilatory status. The chest tube initially remained to suction with air leak noted at each breath. Duration of indwelling catheter placement and need for future surgery was reassessed on a frequent basis. Ultimately, the chest tube was removed after five weeks with permanent involution of pneumatocele. Three weeks later, RC was extubated, and four months after that, RC was discharged home on oxygen.

Management of complications associated with lung disease, including large pneumatoceles, are complex and complicated by the often critical and unstable nature of infants with severe BPD. Successful strategies must be individualized and may require ingenuity and innovation. Thus, it is important to highlight a cooperative and multidisciplinary approach to the care of these patients.