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.