Clinical characteristics of pediatric pneumothorax during a noninvasive positive pressure ventilation

Bo Ra Lee; So Hyun Shin; Min Jung Kim; Eunji Kim; Yun Jung Choi; June Dong Park; Dong In Suh

doi:10.4168/aard.2019.7.1.51

Journal List > Allergy Asthma Respir Dis > v.7(1) > 1125519

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Lee, Shin, Kim, Kim, Choi, Park, and Suh: Clinical characteristics of pediatric pneumothorax during a noninvasive positive pressure ventilation

Original Article

Allergy Asthma Respir Dis 2019;7(1):51-56.

Published online: 12 January 2019

DOI: https://doi.org/10.4168/aard.2019.7.1.51

Clinical characteristics of pediatric pneumothorax during a noninvasive positive pressure ventilation

Bo Ra Lee¹, So Hyun Shin¹, Min Jung Kim¹, Eunji Kim¹, Yun Jung Choi², June Dong Park¹, Dong In Suh¹

^¹Department of Pediatrics, Seoul National University Children's Hospital, Seoul Korea

^²Sowha Children's Hospital, Seoul Korea

Correspondence to: Eunji Kim https://orcid.org/0000-0003-4020-7076 Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-3778, Fax: +82-2-2072-3917, E-mail: mdkim78@naver.com

Received 28 September 2018 Revised 22 October 2018 Accepted 22 October 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

Noninvasive positive pressure ventilation (NIPPV) is one of the ventilation-supporting methods by providing adequate exogenous pressure without intubation or tracheostomy. We aimed to assess the frequency and clinical factors for pneumothorax occurring during NIPPV application in a tertiary children's hospital.

Methods

We selected cases of pneumothorax related to NIPPV by keyword searching in our institution's clinical data warehouse, and their medical records were retrospectively reviewed.

Results

During a period of 17 years, 15 cases undergoing NIPPV developed pneumothorax, which was an incidence of 0.64% (15 of 2,343). There were 9 neonates and 6 adolescents. In 9 neonates, pneumothorax was caused by the continuous positive airway pressure (CPAP) ventilator, and occurred on 2 days after birth (median, range 1–3 days). In neonates, pneumothorax developed within 36 hours after CPAP application. One neonate underwent tracheal intubation and 3 neonates underwent chest tube insertion. In the postteenager group, pneumothorax developed 23 months (median, range 5 days to 47 months) after NIPPV application with a mask. All of the 6 patients had underlying neuromuscular disorders and one had superimposed interstitial lung disease. One of the 7 cases underwent surgical treatment and 4 cases were intubated. One case died from the deterioration of underlying interstitial lung disease.

Conclusion

Although it rarely happens, the NIPPV can result in pneumothorax. In most cases, it can be resolved by supportive cares with oxygen or chest tube with or without tracheostomy. The prognosis is related to the type of underlying disease and its progression.

Keywords: Noninvasive ventilation, Pneumothorax, Respiratory insufficiency

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Fig. 1.

Flow chart of subjects being anlyzed. NIPPV, noninvasive positive pressure ventilation; NICU, neonatal intensive care unit.

Table 1.

Keywords used in defining the case of pneumothorax associated with the noninvasive positive airway pressure ventilatory support

Diagnostic keyword (ICD 10)	Nursing records keyword*
Pneumothorax (J939)	Bilevel positive airway pressure
Pneumothorax in the perinatal period (P251)	Nasal continuous positive airway pressure
Spontaneous tension pneumothorax (J930)	Positive end expiratory pressure
Secondary spontaneous pneumothorax (J931)	Type of ventilator (bipap)^†
Iatrogenic pneumothorax (J938)	Expiratory positive airway pressure
Hydropneumothorax (J948)	EPAP
Hemopneumothorax (J942)	Inspiratory positive airway pressure
Other pneumothorax (J938)	IPAP

ICD 10, International Statistical Classification Of Diseases And Related Health Problems, 10th revision; EPAP, expiratory positive airway presssure.

*During the keyword searching, at least one Korean term of “applying”, “applied” or “changed” were added to the keywords listed below.

^† The original Korean phrases were translated into English ones.

Table 2.

Demographic and clinical characteristics of study patients

Variable	Neonate (n=9)	Adolescence and young adults (n=6)
Male sex	3 (33.3)	5 (83.3)
Age	2 days (1–3 days)	22 years (12–25 years)
Body weight (kg)	1.91 (1.12–3.71)	29.4 (22.5–39.7)
Body mass index (kg/m²)	NA	11.2 (8.0–15.4)
Gestational age at birth (wk)	34.6 (28.4–37.4)	NA
Body weight at birth (kg)	1.94 (1.12–3.72)	NA
NIPPV duration till pneumothorax	12 hours (0.5–30 hours)	23 months (0–47 months)
Underlying disease or conditions (n)	Preterm (6) Term (3)	Muscular dystrophy (4) Myasthenia gravis (1) Dermatomyositis (1)
Predisposing factors (n)	TTN (2) RDS (1) RD of newborn (6)	Pneumonia (2) ILD progression (1)
Initial symptom (n)	Respiratory distress	Dyspnea (2) Chest discomfort (2) Nonspecific (2)
Chest wall deformity	0 (0)	5 (83.3)

Values are presented as number (%) or median (range) unless otherwise indicated.

NA, not available; TTN, transient tachypnea of newborn; RDS, respiratory distress syndrome; RD, respiratory distress; ILD, interstitial lung disease.

Table 3.

Comparison of ventilator mode and setting values between the 2 groups

Variable	Neonate (n=9)	Adolescence and young adults (n=7)
Mode (n)	CPAP (9)	BiPAP, volume (1)
		BiPAP, pressure (6)
PEEP or EPAP (cmH₂ O)	5 (4–7)	6 (5–8)
IPAP (cmH2 O)	NA	7 (5–10)
Mechanical in-exsufflator	0 (0)	2 (28.6)
Type of ventilatory circuit (n)	NA	Active (3) Passive (4)

Values are presented as number (%) or median (range) unless otherwise indicated. CPAP, continuous positive airway pressure; BiPAP, bilevel positive airway pressure; PEEP, positive end expiratory pressure; EPAP, expiratory positive airway pressure; IPAP, inspiratory positive airway pressure; NA, not available.

Table 4.

Comparison of treatment and procedures between the 2 groups

Group	Case	O₂ supply	Chest tube	Intubation	Bullectomy	Tracheostomy
Neonates	1	V	V	V
	2	V	V	V
	3	V	V
	4	V		V
	5	V
	6	V
	7	V
	8	V
	9	V
Adolescents	10*	V	V	V	V
and young	11*	V
adults	12	V	V
	13^†	V	V	V
	14	V	V	V		V
	15	V	V	V		V
	16	V	V	V		V

*Happened in the same person.

^† Expired.

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