Management of neonatal pneumothorax - guideline



Canberra Health ServicesClinical Guideline Management of Neonatal PneumothoraxContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc26187120 \h 1Guideline Statement PAGEREF _Toc26187121 \h 2Background PAGEREF _Toc26187122 \h 2Key Objective PAGEREF _Toc26187123 \h 2Scope PAGEREF _Toc26187124 \h 2Section 1 – Diagnosis of Neonatal Pneumothorax PAGEREF _Toc26187125 \h 2Section 2 – Management of a Pneumothorax PAGEREF _Toc26187126 \h 5Section 3 – Chest Drain Management PAGEREF _Toc26187127 \h 6Implementation PAGEREF _Toc26187128 \h 7Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc26187129 \h 7References PAGEREF _Toc26187130 \h 7Definition of Terms PAGEREF _Toc26187131 \h 7Search Terms PAGEREF _Toc26187132 \h 8Attachments PAGEREF _Toc26187133 \h 8Attachment 1: Needle aspiration of a pneumothorax PAGEREF _Toc26187134 \h 9Attachment 2: Insertion of Safe-T-Centesis drain PAGEREF _Toc26187135 \h 10Guideline StatementBackgroundThe incidence of neonatal pneumothorax is reported to be between 6 and 23% depending on risk factors 1. Neonatal pneumothorax is associated with significant morbidity and mortality.Key ObjectiveThis document will provide neonatal doctors and nurses with guidance related to:Diagnosis of a pneumothoraxManagement of a pneumothoraxNeedle aspiration and chest drain insertionBack to Table of ContentsScopeThis document applies to the following Canberra Health Services (CHS) clinical staff working within their scope of practice:Medical OfficersNurses and midwivesNursing and Midwifery studentsBack to Table of ContentsSection 1 – Diagnosis of Neonatal PneumothoraxRisk factors for pneumothoraxThere are a number of risk factors for neonatal pneumothorax including:Positive pressure ventilation (invasive ventilation or CPAP)Parenchymal lung disease including preterm respiratory distress syndrome, meconium aspiration syndrome, pneumonia or pulmonary hypoplasiaDiagnosis of pneumothoraxSuspect pneumothorax in a newborn with parenchymal lung disease who experiences a deterioration in their clinical status (increased work of breathing, increased Fio2), particularly if they have any of the above risk factors. A suspected pneumothorax can be investigated using transillumination, chest x-ray or lung ultrasound.TransilluminationTransillumination can help to confirm the presence of a clinically suspected pneumothorax. It cannot be used to definitively rule out a pneumothorax. The reported sensitivity of transillumination is 87-100% and specificity 95-100%. When performing a transillumination:right141605Dim the lights in the roomUse the fibreoptic cold light (clean with an alcohol wipe prior to use)Place the probe over the chest wall Compare the two sides of the chestA positive transillumination (suggesting the presence of a pneumothorax) will light up the whole hemi thorax where a negative transillumination will only light up a ring of light around the cold light (see example of positive transillumination to the left) 00Dim the lights in the roomUse the fibreoptic cold light (clean with an alcohol wipe prior to use)Place the probe over the chest wall Compare the two sides of the chestA positive transillumination (suggesting the presence of a pneumothorax) will light up the whole hemi thorax where a negative transillumination will only light up a ring of light around the cold light (see example of positive transillumination to the left) Figure 1: Positive transillumination1 Chest X-ray (CXR):Chest X-ray is generally used to confirm or deny the presence of a clinically suspected pneumothorax. In cases where it is unclear on a supine X-ray whether a pneumothorax is present, it may help to do an X-ray with the newborn on their side (affected side up) and the X-ray plate behind their back and shooting the X-ray from the newborn’s front to back (lateral decubitus). It is difficult to interpret the size of a pneumothorax on a supine film. Clinical symptoms associated with pneumothorax are more important than size when deciding which patients need to have their pneumothorax drained.528320698500352869569850021094701593850050812709461600514794570485002738120508000Figure 2: Examples of left sided tension pneumothoraxLung Ultrasound:For clinicians with experience in using ultrasound, lung ultrasound has been shown to be a quick and effective method of diagnosing pneumothorax. At CHS this should only be used by a consultant trained in the use of clinician performed ultrasound, as an adjunct to clinical assessment. 212852010795In a normal neonatal lung ultrasound (longitudinal view):The pleural lines are visible beneath the ribs. These slide over one another during normal breathingA-lines are visible (parallel lines that represent reverberation artefact in healthy lung)You see drop out between the ribs (not always the case in preterm newborns)You may see B lines which vertical lines are also thought to represent alveolar reverberation. 00In a normal neonatal lung ultrasound (longitudinal view):The pleural lines are visible beneath the ribs. These slide over one another during normal breathingA-lines are visible (parallel lines that represent reverberation artefact in healthy lung)You see drop out between the ribs (not always the case in preterm newborns)You may see B lines which vertical lines are also thought to represent alveolar reverberation. left8000900229997012700M-mode normal lung ultrasoundThe ‘sea shore sign’ is indicative of normal lung sliding (i.e. no pneumothorax)00M-mode normal lung ultrasoundThe ‘sea shore sign’ is indicative of normal lung sliding (i.e. no pneumothorax)Figure 2: Example of normal lung ultrasound3left2228311B-lines00B-lines37568632124446M-modeNo Pneumothorax00M-modeNo Pneumothorax23776082116743M-modePneumothorax00M-modePneumothorax3014345750570Lung point (transition between the two)00Lung point (transition between the two)Figure 3: Examples of ultrasound signs described when examining for pneumothorax3In real time the ‘sliding’ of lung tissue is absent as are the ‘A lines’ (top left). There are comet signs in the lower left image representing B lines (their presence rules out pneumothorax). In M-mode the seashore sign is absent and there are horizontal lines called the ‘barcode’ or ‘stratosphere’ sign. This is due to an absence of sliding and is consistent with a diagnosis of pneumothorax. The line between the ‘seashore’ and ‘stratosphere’ signs is the physical edge of the pneumothorax (lung point).Ultrasound signClinical utilitySlidingSide to side horizontal movement of the parietal pleuraPresence of lung sliding has a sensitivity 95%, specificity 91-94% for absence of a pneumothorax3B-linesVertical artefact that implies the presence of parietal pleuraPresence of a B-line or comet tail rules out pneumothorax (visceral pleura is present) NPV 99-100%3Lung pointPoint where lung sliding restarts on the border of a pneumothoraxPresence of lung point has a sensitivity 66%, specificity 100% for predicting pneumothoraxLung pulseFeature of atelectatic lung where the lung pulsates in time with the heart beatPresence implies complete atelectasis or a pneumothoraxSigns of pneumothorax on lung ultrasound2,3Back to Table of Contents Section 2 – Management of a PneumothoraxConservative treatment:Pneumothoraces may spontaneously occur in term newborns. A well term newborn without significant underlying lung disease is likely to remain well with supportive management. CHS recommends draining pneumothoraces in:Preterm symptomatic newborns <37 weeks gestationNewborns with underlying lung disease Any with a large pneumothorax who requires a significant amount of oxygen or respiratory support Any showing evidence of a tension pneumothorax (tachycardia, hypotension, acidosis, poor perfusion)At consultant discretionNeedle aspiration (see attachment 1):If a newborn is cardiovascularly compromised with a suspected tension pneumothorax, a needle aspiration should be performed prior to the insertion of a chest drain.Term newborns without underlying lung disease may have a needle aspiration performed as primary treatment for pneumothorax providing a person skilled in drain insertion is available. Needle aspiration alone has been shown to be insufficient treatment for newborns <32 weeks 82% of the time and newborns >32 weeks 53% of the time5.Only one needle aspiration should be performed as primary elective treatment for a pneumothorax. Chest drain insertion (see attachment 2):A chest drain should be inserted in any preterm newborn (<37 weeks) with a significant pneumothorax and in any term newborn with significant underlying lung disease.There is evidence that pigtail catheters are quicker to insert than traditional chest drains and work as effectively4. There has been a suggestion in the literature that they are associated with fewer complications and less pain during insertion.6Complications:Pain associated with chest drain insertion, may require pharmacological treatment. Drains may kink or fall out. Serious complications are rare. These include organ injury (particularly lung injury, although mediastinal or abdominal organ injuries can occur), bleeding, infection and pneumothorax.Back to Table of Contents Section 3 – Chest Drain ManagementWhen a chest drain is in the intrapleural space it should ‘swing’ with breathing (water level rising with inhalation and falling with exhalation)While air is still draining from the intrapleural space a chest drain should ‘bubble’If a drain stops ‘bubbling’ or ‘swinging’, particularly in the context of clinical deterioration, it’s important to suspect that it may be blocked/have dislodged. Similarly, if a drain is bubbling excessively this may be a result of a ‘leak’ in the tubing or the drain being outside of the pleural space.Nursing care of a chest drain:Secure the tubing to the bed to ensure there is no pulling on the tube– encircle the tube with adhesive tape and pin the tape to the bed Check hourly for bubble and swing in the chamber and document on the observation chartComplete a pain score hourly and administer analgesia/sedation as ordered Check dressing is intact and airtight at the insertion site; observe for any drainage or leaking from same. Do not change if dry and intactObserve for signs of infection - erythema and purulent discharge around drain site and/or purulent discharge in drainage Check the system is connected to low wall suction at between 5-10kpa if requested Stabilise the tube when moving the newborn by holding it close to their chestCheck that the underwater seal drainage system is positioned below the level of the newborn’s chest to prevent water from being drawn into the pleural space Check clamps are available at the bedside to clamp tube if disconnected and during changing of the drainage system when necessary If disconnection occurs immediately reconnect and inform the Medical Officer Monitor and record the amount, colour and consistency of the drainage hourly on the observation chartBack to Table of Contents Implementation This guideline is an update of an old guideline. It will be used predominantly in the Neonatal Intensive Care Unit. It will be referred to during the orientation of new staff to the department. Current staff will be educated regarding this guideline update. All staff will be informed of the updated guideline at the relevant quality and safety meeting and via email to all staff.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationGuidelines - Canberra Health Services Clinical Procedure Ventilation – Invasive and Non-Invasive (Neonates and Infants)Back to Table of ContentsReferencesWaisman et al, Perinatal/Neonatal Case Presentation Chest dynamics asymmetry facilitates earlier detection of pneumothorax Journal of Perinatology volume 36, pages 157–159 (2016)Hany Aly, An Massaro, Ceyda Acun & Maide Ozen (2014) Pneumothorax in the : clinical presentation, risk factors and outcomes, The Journal of Maternal-Fetal & Neonatal Medicine, 27:4, 402-406Jing Liu (2014) Lung ultrasonography for the diagnosis of neonatal lung disease, The Journal of Maternal-Fetal & Neonatal Medicine, 27:8, 856-861Wei et al, Pigtail Catheters Versus Traditional ChestTubes for Pneumothoraces in Premature Newborns Treated in a Neonatal Intensive Care Unit, Pediatrics & Neonatology, 2014-10-01, Volume 55, Issue 5, Pages 376-380.Murphy et al, Effect of Needle Aspiration of Pneumothorax on Subsequent Chest Drain Insertion in s A Randomized Clinical Trial JAMA Pediatr. 2018;172(7):664-669. Cates, Pigtail catheters used in the treatment of pneumothoraces in the neonate, Adv Neonatal Care. 2009 Feb;9(1):7-16Back to Table of ContentsDefinition of TermsPneumothorax: Collection of air between the parietal and visceral pleuraBack to Table of ContentsSearch Terms Neonatology, Pneumothorax, Pleural Effusion, Chest drain, Needle aspiration, NICUBack to Table of ContentsAttachmentsAttachment 1: Needle aspiration of a pneumothoraxAttachment 2: Insertion of Safe-T-Centesis drainDisclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 15 May 19 Complete ReviewTina Bracher, ED WY&CCHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameCHHS15/100Transillumination and chest drain management (neonates)Attachment 1: Needle aspiration of a pneumothoraxIndication:Emergency treatment of a tension pneumothoraxPrimary treatment of a pneumothorax in term babies Equipment:Dressing packChlorhexidine20ml syringe3 way tapBlue butterfly needle or cannula Procedure:Ensure the newborn’s saturation, heart rate and respiratory rate are continuously monitoredWear sterile glovesAttach the syringe and the butterfly needle/cannula to the 3-way tapPlace into position with the arm of the affected side restrained at a 90-degree angle???The involved side should be exposed and slightly elevated to ensure evacuation of air? Clean the newborn ’s skin with chlorhexidine in the area of the 2nd-3rd rib along the mid clavicular linePlace a finger on the newborn ’s 3rd rib and guide the needle along the finger and insert into the 2nd intercostal space just above the superior margin of the 3rd rib at an angle of 90degreesAvoid the nipple and surrounding tissueAspirate air from the chestContinue to aspirate until resistance is met, then remove needle/cannula (you may need to empty the syringe using the 3-way tap if there is a lot of air)Document the procedure in the notes including the amount of air removed in millilitresRepeat the chest X-ray to confirm drainage of pneumothorax Attachment 2: Insertion of Safe-T-Centesis drainThe Safe-T-Centesis is a soft flexible intercostal catheter that is introduced using a needle that is self-blunting (i.e. sharp when pressed into tissue and then covered by a blunt cover once the tip is in the thoracic cavity.)Indication:Treatment of a pneumothorax or pleural effusionContraindication/Precaution:Avoid inserting a chest drain when there is untreated coagulopathy or thrombocytopenia (platelet count <80,000)Equipment:Analgesia (sucrose, morphine and 1% lignocaine)Sterile gown and gloves/mask and hatSterile drapeSterile dressing packSafe –T- Centesis pigtail catheter pack (use a 6Ch for small preterm newborns and an 8Ch for larger newborns)Underwater drain or Heimlich valveScissorsLuer lock to drain adaptors (see picture immediately below) Safe-T-centesis pack1 Self-blunting introducing needle with syringe attached 2 Pigtail catheter3 Scalpel4 Needle thoracentesis needle and tube (note: the pictured example is NOT appropriately sized for neonatal use)Procedure:Step 1: PreparationSterile precautions including scrub/gown/gloves and mask Ensure that the newborn has full cardiorespiratory monitoringAdminister analgesia (sucrose, local anaesthetic, morphine)Position the with their affected chest wall slightly upCheck equipment and attach a 20 ml syringe to the Safe-T-Centesis system 3-way tapStep 2: preparation once scrubbedClean the area with chlorhexidine 0.2% and drape the newborn’s chest wallIdentify the 4th or 5th intercostal space in the mid to anterior axillary line making sure to avoid the nipple and any surrounding breast tissueAdminister local anaesthesia and await effectStep 3: Chest drain insertionMake a small 3-5mm incision at the insertion site immediately above the lower rib (to avoid injuring the neurovascular bundle). The incision is through the skin only.Introduce the Safe-T-Centesis introducer gently through the intercostal space and pleura. Apply firm pressure to get through the muscle and pleura. Guard the introducer with one of your hands by holding it approximately 2 cm from the tip to avoid advancing too far once there is a ‘give’ or a ‘pop’ when going through pleura.Direct the introducer superiorly and anteriorly (pneumothorax) or posteriorly and inferiorly (pleural effusion) about 1-2 cm and then feed the drain to the desired depth over the top of the introducer. When the needle has a cutting edge the hub is red, once it’s not in contact with tissue it self-blunts and the hub is white.Ensure that the drain in inserted at least 4 cm so that all of the catheter holes are in the chest (there are holes up to 3cm). 3157221100331003128645165036545770801344930Blunt edge00Blunt edge4533900370205Cutting edge00Cutting edge3058688113316300309308523558500363683643084Aspirate air using the syringe attached to the 3 way tap to drain pneumothorax/fluid and confirm position.Remove the introducing needle through the self-sealing valveStep 4: Secure the drainSecure the drain to the skin using steri-stripsCreate a ‘sandwich’ using two TegadermsRCreating additional security by placing brown tape to anchor the drain to the abdomen or lower down the chest wall (DuodermR can be used under the tape)-120015201930379222029781520034251206500Step 5: Connect to the underwater seal (in NICU) or Heimlich valve (transport)4236720889000Cut the end off the chest drain tubing (see image to the right)Attach the Luer-lock adaptor to the drain adaptor and the 3 way tapAttach to underwater drain or Heimlich ValveR and ensure that you can see swinging with respiration and/or bubbling (underwater drain) or fluttering (Heimlich Valve) if there is ongoing drainage of intrathoracic air.3108325311785-13843064135Step 6: Confirm position with a CXR and document the procedure in the newborn’s medical record. ................
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