Neonatal air-leak syndromes — formative SAQs

SAQ 1 — The deteriorating ventilated preterm (10 marks)

A 27-week gestation, 850 g infant is day 2 of life, ventilated for respiratory distress syndrome on synchronised intermittent mandatory ventilation. The nurse calls you because the infant has suddenly desaturated to 60%, the heart rate has fallen to 80, and the peak inspiratory pressure has risen. The left hemithorax appears full and moves less than the right. Blood pressure is 28/16. [9]

a) What is the most likely diagnosis, and what single bedside test supports it at the cot side? (2 marks) [9]

The most likely diagnosis is a left tension pneumothorax in a ventilated preterm infant with sudden deterioration, reduced left air entry, a full hemithorax, and cardiovascular compromise (hypotension, bradycardia). The single bedside test is cold-light fibreoptic chest transillumination, which will show a bright halo over the left hemithorax. [9]

b) Describe your immediate management, including the specific technique you would use and why you would not await imaging. (4 marks) [9]

The immediate management is emergency needle aspiration of the left hemithorax before any radiograph. This infant is unstable (hypotensive, bradycardic) with a clear clinical picture and a clear transillumination halo — the standard is to decompress first and image after. [1] [9]

Technique: insert a 21 to 23 gauge butterfly needle or cannula into the second intercostal space in the mid-clavicular line on the left, aiming just above the rib to avoid the neurovascular bundle, connected to a three-way tap and syringe, and aspirate air. [9] The hiss of escaping air and immediate clinical improvement confirm the diagnosis.

c) After initial decompression, what definitive procedure is required, and describe one modern device and its advantage over the traditional alternative? (2 marks) [11]

Because the infant is ventilated, the pneumothorax will recur once the needle is removed, so a definitive chest drain is required. The modern device is a pigtail catheter (8–10 French, Seldinger technique), whose advantage over the traditional Malécot chest drain is less tissue trauma, a smaller incision, and fewer complications (lung injury, bleeding, phrenic nerve injury). [11]

d) State the prevention bundle that reduces the risk of air leaks in preterm infants, citing the evidence base. (2 marks) [4]

The prevention bundle comprises antenatal corticosteroids, early surfactant for RDS, synchronised and volume-targeted ventilation, permissive hypercapnia with minimal effective PEEP, and avoidance of mask over-ventilation in the delivery room. [4] [6] [7] The evidence base is a chain of Cochrane reviews showing reduced air leaks with each element.