Paeds Cases · fetal-neonatal-and-perinatal
Sudden deterioration in a ventilated preterm — tension pneumothorax
OSCE on a ventilated preterm infant with an acute tension pneumothorax, testing the decompress-before-image principle, needle aspiration technique, definitive chest-drain choice, and the prevention bundle.
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MRCPCH ClinicalRACP DCERCPSC Pediatrics
Prompt
A 27-week, 850 g infant on day 2 of life, ventilated for respiratory distress syndrome, suddenly desaturates, becomes bradycardic and hypotensive, with a full left hemithorax and reduced left air entry; the candidate must perform the focused assessment, transilluminate, decide on emergency decompression before imaging, describe the needle aspiration technique, choose the definitive drain, and state the prevention bundle.
Clinical information for the examiner
Setting: Tertiary NICU, day 2 of life. Infant is ventilated on synchronised intermittent mandatory ventilation (PIP 18, PEEP 5, rate 40, FiO₂ 0.30) for respiratory distress syndrome. Antenatal steroids were given; one dose of surfactant was administered at birth. [1]
On your arrival:
- Heart rate 80 bpm (was 145), SpO₂ 60% (was 95%), blood pressure 28/16 (mean 20, was 40). [9]
- Left hemithorax appears full and moves less than the right.
- Reduced air entry on auscultation of the left axilla.
- Apical impulse shifted toward the right.
- Capillary refill 4 seconds; infant is pale and poorly perfused. [1]
- Cold-light transillumination over the left anterior chest shows a bright halo. [9]
References6ShowHide
- [1]Aziz K Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics, 2021.PMID 33087555
- [3]Jeng MJ Neonatal air leak syndrome and the role of high-frequency ventilation in its prevention. J Chin Med Assoc, 2012.PMID 23158032
- [4]Rojas-Reyes MX Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev, 2012.PMID 22419276
- [9]Huseynov M Neonatal pneumothorax from the perspective of a pediatric surgeon: classification and management protocol: a preliminary algorithm. Turk J Med Sci, 2021.PMID 33433972
- [11]Cates LA Pigtail catheters used in the treatment of pneumothoraces in the neonate. Adv Neonatal Care, 2009.PMID 19212159
- [12]Greenough A Pulmonary interstitial emphysema. Arch Dis Child, 1984.PMID 6508339