Discussion:
The incidence of pneumatoceles has decreased dramatically since the advent of surfactant and advances in ventilation of neonates.1 Interventional decompression of pneumatoceles is generally not necessary unless a patient is unstable, as was the case in our patient. While surgical options were available, this patient was unlikely to tolerate lower lobectomy or functional pneumonectomy. Therefore, their decompensating clinical condition warranted a rapid nonsurgical approach. Unilateral intubation was perceived as inadequate to successfully ventilate the patient and there were concerns for the in-situ endotracheal tube being too large for advancing to mainstem. Ventilation with high frequency oscillation was also considered inadequate but was not attempted. Management with two chest tubes was unsuccessful due to rapid re-accumulation of air within the patient’s pneumatocele and thorax; these tubes were noted to have managed the initial mass effect from the pneumatocele though. This failure was considered to be the result of air flowing from the ETT and preferentially though the patient’s affected lung, then proceeding through the pneumatocele and directly out of the chest cavity via the chest tubes, reducing the ventilation of the contralateral lung. This explains the back-and-forth seen initially in our patient, in which clamping the patient’s chest tube would temporarily improve oxygen saturations until enough air reaccumulated in the lung affected by the pneumatocele to compress the mediastinum and contralateral lung.
Insertion of a Fogarty catheter has been described in the operating room setting, but emergent bedside insertion into the pneumatocele alongside an in-situ ETT is a technique not previously reported in the literature. A case series by Malik et al. does report and illustrate the use of a Fogarty catheter to successfully decompress a pneumatocele in multiple neonates.4 However, both patients in this case series were not managed at bedside, nor were their catheters placed alongside a pre-existing ETT. There are novel benefits to our technique. First, by passing the catheter next to the ETT the patient remained intubated which improved the safety profile of the procedure and does not expose the patient to the unnecessary risk of extubation and reintubation. Second, deflation of the balloon allowed for reassessment and adjustment of the catheter position, arguably more safely than attempting to isolate an entire lung; during whole lung isolation it is possible for the balloon to be moved too far superiorly and ultimately block the patient’s trachea. Third, the addition of contrast dye to the catheter balloon assisted with imaging and confirmed placement. The balloon was then reinflated to selectively block portions of the lung and isolate the pneumatocele. This combination of plain radiography and the measurement feature of portable radiography to the authors knowledge has also never been reported in the literature.
While our patient ultimately expired due to exhaustion and difficulty securing the tube, catheter insertion produced significant improvements in the patient’s oxygen status. Our patient was successfully temporized, and it is possible had the pediatric anesthesia team been involved earlier in our patient’s course, earlier catheter insertion may have stabilized the patient beyond a few days and perhaps may even have been a bridge to surgical intervention, such as the aforementioned lobectomy or pneumonectomy.
Additionally, it should be mentioned that our patient was not considered a candidate per the pediatric surgery service and our institutional policy. Current literature reports a relative contraindication to ECMO for patients less than 34 weeks gestational age or less than two kg, as was the case with our patient.5
In conclusion, pneumatoceles are a known source of increased neonatal mortality. Their successful management via modified patient position, unilateral lung intubation, percutaneous catheter placement, and surgical management. While management of pneumatocele via Fogarty catheter placement has been reported in the literature, the technique described in this case report uniquely describes a successful bedside placement and with an existing endotracheal tube in place to continuously maintain an airway.