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

Pulmonary Interstitial Emphysema: Treatment & Medication

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

Treatment

Medical Care

Different treatment modalities have been used to manage pulmonary interstitial emphysema (PIE), with variable success.

  • Lateral decubitus positioning16
    • This conservative approach has been used with success and is most effective in infants with unilateral pulmonary interstitial emphysema. The infant is placed in the lateral decubitus position with the affected lung in a dependent position. This therapy can result in plugging of dependent airways and improved oxygenation of the nondependent lung. The latter allows for overall decreased ventilatory settings. The combination of the above factors helps in resolution of pulmonary interstitial emphysema.
    • In different case studies of lateral decubitus position as a treatment of unilateral pulmonary interstitial emphysema in infants, pulmonary interstitial emphysema resolved in 48 hours to 6 days with minimal recurrence and a low failure rate. Lateral decubitus positioning should be considered as an early first-line therapy in the management of unilateral pulmonary interstitial emphysema. Lateral decubitus positioning has been used successfully for patients with bilateral pulmonary interstitial emphysema when one side is more significantly affected.
  • Selective main bronchial intubation and occlusion
    • Many case reports detail successful treatment of severe localized pulmonary interstitial emphysema in infants with selective intubation of the contralateral bronchus to decompress the overdistended lung tissue and to avoid exposing it to high positive inflationary pressures17,18,19 . Selective bronchial intubation of the right main bronchus is not a difficult procedure; the left side may be more difficult. The endotracheal tube of the same diameter as for a regular intubation is inserted 2-4 cm beyond its usual position. It is introduced with the bevel on the end of the tube positioned so that the long part of the tube is toward the bronchus to be intubated. This increases the chance of entering the correct bronchus as the tube is advanced into the airway. Turning the infant's head to the left or right moves the tip of the endotracheal tube to the contralateral side of the trachea and may help in selective tube placement.
    • Weintraub et al have described a method for left selective bronchus intubation using a regular Portex endotracheal tube in which an elliptical hole 1 cm in length has been cut through half the circumference 0.5 cm above the tip of the oblique distal end.19 With the side with the elliptical hole directed to the left lung, left selective bronchus intubation can be easily and repeatedly accomplished. Another method of selective intubation is the use of a small fiberoptic bronchoscope to direct the endotracheal tube tip into the desired bronchus. Selective intubation under fluoroscopy can also be considered.
    • Potential complications of the selective intubation/ventilation include atelectasis in the affected lung, injury to bronchial mucosa with subsequent scarring and stenosis, acute hypoventilation or hypoxemia if ventilating one lung is inadequate, excessive secretions, hyperinflation of the intubated or nonoccluded lung, upper lobe collapse when intubating the right lung, and bradycardia. Despite potential risks, selective bronchial intubation is a desirable alternative to lobectomy in a persistent, severe, localized pulmonary interstitial emphysema causing mediastinal shift and compression atelectasis and not responding to conservative management. This procedure should be attempted before any surgical intervention.
  • High-frequency ventilation
    • Keszler et al studied use of high-frequency jet ventilation (HFJV) in 144 newborns with pulmonary interstitial emphysema.20 They concluded that HFJV was safe and more effective than rapid-rate conventional ventilation in the treatment of newborns with pulmonary interstitial emphysema. With HFJV, similar oxygenation and ventilation was obtained at lower peak and mean airway pressures, suggesting that, in infants with pulmonary interstitial emphysema, a reduction in the amount of air leaking into the interstitial spaces would occur.
    • Similar effects can be achieved by use of HFOV.
      • In a study by Clark et al, 27 low birth weight infants who developed PIE and respiratory failure while on conventional ventilation were treated with HFOV.21 Surviving patients showed continued improvement in oxygenation and ventilation at an increasingly lower fraction of inspired oxygen (FiO2) and proximal airway pressure with resolution of pulmonary interstitial emphysema, whereas nonsurvivors progressively developed chronic respiratory insufficiency with continued pulmonary interstitial emphysema from which recovery was not possible. Overall survival in nonseptic patients was 80%.
      • They found HFOV to be effective in the treatment of pulmonary interstitial emphysema and hypothesized that interstitial air leak is decreased during HFOV because adequate ventilation is provided at lower peak distal airway pressures. Although this mode of ventilation has inherent risks, it can be a very effective tool in experienced hands for the treatment of severe diffuse pulmonary interstitial emphysema. Care must be taken in smaller infants who require a high amplitude to ventilate because the active exhalation during HFOV may cause small airway collapse and exacerbate gas trapping.
  • Other treatment modalities
    • Case reports and/or case series describe different approaches for the management of pulmonary interstitial emphysema, including 3-day course of dexamethasone (0.5 mg/kg/d),22 chest physiotherapy with intermittent 100% oxygen in localized and persistent compressive pulmonary interstitial emphysema,23 artificial pneumothorax,24,25 and multiple pleurotomies.26
    • Despite success claimed by the authors, the efficacy of these treatment modalities from these case reports seems questionable. With advancements in respiratory care, these treatment modalities rarely are used.

Surgical Care

Lobectomy is indicated in a small number of patients with localized pulmonary interstitial emphysema when spontaneous regression is not occurring and medical management has failed.27,28,29 Although clear guidelines for surgical intervention are difficult to establish, it should be reserved for infants in whom the risks of recurring complications outweigh those of surgery. It seems most helpful in infants who develop severe lobar emphysema.

Consultations

All infants with pulmonary interstitial emphysema need to be under the care of a neonatologist. In some cases, pediatric pulmonology and pediatric surgery consultations are appropriate.

Diet

The overall importance of appropriate nutritional management of ill newborns cannot be overstressed. Most of these infants are treated with total parenteral nutrition and require diligent attention.

More on Pulmonary Interstitial Emphysema

Overview: Pulmonary Interstitial Emphysema
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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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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