Minimally invasive treatment of retrocardiac tension pneumomediastinum in an extremely low birth weight infant
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CASE REPORT
Minimally invasive treatment of retrocardiac tension pneumomediastinum in an extremely low birth weight infant Michael J. Ponkowski 1 & Bhupender Yadav 2 & Elisabeth Meagher 2 & Anthony Ho 2
&
Ranjith Vellody 2
Received: 10 December 2019 / Revised: 25 March 2020 / Accepted: 12 May 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract A 23.4-week premature and extremely low birth weight neonate was transferred to the Neonatal Intensive Care Unit for management of respiratory failure and retrocardiac pneumomediastinum, suspected to be the result of a low tracheal injury during intubation. Initial conservative management failed and chest radiographs demonstrated worsening retrocardiac pneumomediastinum. Due to the patient’s extreme low birth weight and location of the pneumomediastinum, surgery was deemed to be very high risk and potentially fatal. We report the successful definitive percutaneous management of retrocardiac tension pneumomediastinum with a minimally invasive bedside method using an intercostal paraspinal approach under the guidance of ultrasound and plain radiography. Keywords Extremely low birth weight . Interventional radiology . Low tracheal injury . Neonate . Pneumomediastinum . Ultrasound
Introduction Neonates are very susceptible to air leak syndromes secondary to ventilation-related barotrauma. Pneumomediastinum is the third most-common air leak syndrome after pulmonary interstitial emphysema and pneumothorax [1]. Apart from ventilationassociated barotrauma, tracheal and esophageal perforations can also cause pneumomediastinum, especially when seen in a retrocardiac location [2]. Isolated retrocardiac pneumomediastinum is extremely rare in neonates and is life threatening if it is progressive as it can lead to cardiac tamponade physiology [3]. No recommendations exist in the literature to guide management of symptomatic retrocardiac pneumomediastinum in the neonatal population. Most patients benefit from continued mechanical ventilation along with con-
* Anthony Ho [email protected] Ranjith Vellody [email protected] 1
Michigan State University College of Human Medicine, 15 Michigan St. NE, Grand Rapids, MI 49503, USA
2
Interventional Radiology, Children’s National Hospital, 111 Michigan Ave. NW, Washington, DC 20010, USA
servative management. Surgical intervention is also considered depending on the patient’s clinical status [3–5]. Managing symptomatic retrocardiac tension pneumomediastinum in extremely low birth weight premature infants has its own unique challenges as depicted in this case report. A combination of ultrasound (US) and plain radiography can be used to definitively treat this condition in patients who are deemed too fragile for surgical management or cannot be moved outside of the NICU (neonatal intensive care unit).
Case report A 540 g female was born at 23.4 weeks’ gestation via cesarean section secondary to premature rupture of membranes and concern for chorioamnionitis. Apgar scores were 4 and 7 at 1 and 5 min, respective
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