eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Pulmonary Interstitial Emphysema: Follow-up

Author: Abhay J Bhatt, MD, MBBS, Assistant Professor, Department of Pediatrics, Division of Newborn Medicine, University of Mississippi Medical Center
Coauthor(s): Rita M Ryan, MD, Professor of Pediatrics, Chief, Division of Neonatology, Director, Neonatal-Perinatal Medicine Fellowship Program, University at Buffalo, State University of New York, Women's and Children's Hospital of Buffalo
Contributor Information and Disclosures

Updated: Apr 16, 2009

Follow-up

Further Inpatient Care

  • Admission/transfer to a NICU is indicated for patients with pulmonary interstitial emphysema (PIE).
  • A thoracentesis set should be readily available due to the possibility of air leak, including pneumothorax and pneumopericardium.

Further Outpatient Care

  • Monitoring for physical and psychomotor development in a neonatal follow-up care program or equivalent program is important because most infants with pulmonary interstitial emphysema are premature and are at risk for developmental delay. In addition, pulmonary interstitial emphysema has been associated with increased risks of intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL), which also increase the risks of developmental delay in these infants.
  • Patients with chronic lung disease may need pediatric pulmonology follow-up care.

Deterrence/Prevention

  • Surfactant
    • Prophylactic surfactant administration to infants (<30-32 weeks' gestation) judged to be at risk of developing respiratory distress syndrome (RDS) compared with selective use of surfactant in infants with established RDS has been demonstrated to decrease the risk of pulmonary interstitial emphysema.30
    • Metaanalysis of early surfactant replacement therapy with brief ventilation compared with later, selective surfactant replacement and continued mechanical ventilation suggests a trend towards a decreased incidence of air leak syndromes in premature infants in the early surfactant group. Early surfactant treatment, less invasive ventilatory support, or both could be responsible factors for the observed beneficial trend.31
    • According to one report, in infants with respiratory distress, multiple doses of animal-derived surfactant extract resulted in greater improvements in oxygenation and ventilatory requirements, a decreased risk of pneumothorax, and a trend toward improved survival.32
  • High-frequency ventilation
    • In a study comparing high-frequency positive pressure ventilation (HFPPV) to conventional ventilation, Pohlandt et al reported a reduction in the risk of pulmonary interstitial emphysema with HFPPV.33 Review of different trials of elective high-frequency oscillatory ventilation (HFOV) versus conventional ventilation for acute pulmonary dysfunction in preterm infants suggests an increase in the incidence of air leak syndromes including but not limited to pulmonary interstitial emphysema in the HFOV group.34
    • A prospective randomized multicenter study of HFOV versus conventional ventilation in premature infants with RDS showed no difference in the incidence of pulmonary interstitial emphysema.35 Limited data regarding rescue HFOV for pulmonary dysfunction in the preterm infant also showed no difference in the rate of pulmonary interstitial emphysema.36
    • Cochrane reviews of trials of elective high-frequency jet ventilation (HFJV)versus conventional ventilation for RDS demonstrated no significant difference in the incidence of air leak syndrome in the individual trials or in the overall analysis37 .
    • In summary, current literature suggests that elective or rescue high-frequency ventilation does not prevent the development of pulmonary interstitial emphysema.
  • Other considerations
    • Different modes of conventional ventilation: No significant difference in the rate of pulmonary interstitial emphysema was found either in pooled analysis within subgroups or overall pooled analysis of trials comparing volume-targeted versus pressure-limited ventilation in the neonate.38
    • Avoid use of high peak inspiratory pressure (PIP).
    • Be careful (watch manometer) during manual ventilation.

Complications

  • Death
  • Respiratory insufficiency
  • Other air leaks
    • Pneumomediastinum
    • Pneumothorax
    • Pneumopericardium
    • Pneumoperitoneum
    • Subcutaneous emphysema (rare)
  • Massive air embolism
  • Chronic lung disease of prematurity
  • Intraventricular hemorrhage
  • Periventricular leukomalacia

Prognosis

  • Long-term follow-up data are scarce.
  • Gaylord et al demonstrated a high (54%) incidence of chronic lung disease in survivors of pulmonary interstitial emphysema compared with their nursery's overall incidence of 32%. In addition, 19% of the infants developed chronic lobar emphysema; 50% received surgical lobectomies.4

Miscellaneous

Medicolegal Pitfalls

  • Although the primary risk factor for pulmonary interstitial emphysema, prematurity, is rarely preventable, attention should be given to the use of as little mechanical ventilatory support as is necessary for the patient's very fragile lungs.
  • Because pneumothorax is a known complication, anticipatory guidance for this possibility should be provided for all those caring for the infant. Appropriate personnel should be readily available to address this complication.
 


More on Pulmonary Interstitial Emphysema

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Differential Diagnoses & Workup: Pulmonary Interstitial Emphysema
Treatment & Medication: Pulmonary Interstitial Emphysema
Follow-up: Pulmonary Interstitial Emphysema
Multimedia: Pulmonary Interstitial Emphysema
References
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References

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  36. Bhuta T, Henderson-Smart DJ. Rescue high frequency oscillatory ventilation versus conventional ventilation for pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev. 2000;(2):CD000438. [Medline].

  37. Bhuta T, Henderson-Smart DJ. Elective high frequency jet ventilation versus conventional ventilation for respiratory distress syndrome in preterm infants. Cochrane Database Syst Rev. 2000;(2):CD000328. [Medline].

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Further Reading

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Keywords

pulmonary interstitial emphysema, PIE, respiratory distress syndrome, RDS, meconium aspiration syndrome, MAS, amniotic fluid aspiration, intrapulmonary pneumatosis, intrapleural pneumatosis, pneumomediastinum, pneumothorax, pneumopericardium, pneumoperitoneum, subcutaneous emphysema, bronchopulmonary dysplasia, chronic lobar emphysema, intraventricular hemorrhage, IVH, prematurity, very low birth weight, perinatal asphyxia, neonatal sepsis, pneumonia, positive pressure ventilation

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Contributor Information and Disclosures

Author

Abhay J Bhatt, MD, MBBS, Assistant Professor, Department of Pediatrics, Division of Newborn Medicine, University of Mississippi Medical Center
Abhay J Bhatt, MD, MBBS is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Rita M Ryan, MD, Professor of Pediatrics, Chief, Division of Neonatology, Director, Neonatal-Perinatal Medicine Fellowship Program, University at Buffalo, State University of New York, Women's and Children's Hospital of Buffalo
Rita M Ryan, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Steven M Donn, MD, Professor of Pediatrics, Director, Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan Health System
Steven M Donn, MD is a member of the following medical societies: American Pediatric Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Brian S Carter, MD, FAAP, Professor of Pediatrics (Neonatology), Vanderbilt University School of Medicine; Co-director, Pediatric Advance Comfort Team, Monroe Carell Jr Children's Hospital at Vanderbilt
Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Society for Bioethics and Humanities, American Society of Law Medicine and Ethics, National Hospice and Palliative Care Organization, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Carol L Wagner, MD, Professor of Pediatrics, Medical University of South Carolina
Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD, Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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