A pneumothorax is the partial or complete collapse of a lung due to a build-up of air between the lung and the chest wall.
This disorder may develop in newborns who are premature, who have a lung disorder such as respiratory distress syndrome or meconium aspiration syndrome, or who are treated with continuous positive airway pressure (CPAP) or a ventilator.
The lung may collapse, breathing may be difficult, and blood pressure may decrease.
The diagnosis is usually suspected based on breathing trouble or low oxygen levels and is confirmed with a chest x-ray.
Newborns who have trouble breathing are given oxygen, and sometimes air is removed from the chest cavity using a needle and syringe or a plastic drainage tube that is left in place.
(See also Overview of General Problems in Newborns and Pneumothorax in adults.)
A pneumothorax is a type of air-leak syndrome. When air leaks out of a lung and into the space around the lungs, it cannot escape and can build up. This build-up of air puts pressure on a lung, so it cannot expand as much as it normally should when a newborn takes a breath.
A large pneumothorax can cause severe difficulty breathing as well as problems with the heart. If enough air accumulates in the space between the lung and the chest wall, the veins that bring blood to the heart are compressed. As a result, less blood fills the chambers of the heart, the output of the heart decreases, and the newborn’s blood pressure decreases. This is called tension pneumothorax.
Pneumothorax most often occurs in newborns with stiff lungs, such as newborns who are premature or who have respiratory distress syndrome or meconium aspiration syndrome.
Pneumothorax can also occur as a complication resulting from the use of continuous positive airway pressure (CPAP) or a ventilator. CPAP is a technique that allows newborns to breathe on their own while receiving slightly pressurized air or oxygen, and a ventilator is a machine that helps air get in and out of the lungs. Because both of these treatments push air into the lungs under pressure (rather than air being sucked in as during normal breathing), they can injure the lungs and create air leaks, especially when the lungs are already stiff.
Pneumothorax can occasionally happen spontaneously in newborns who do not have an underlying lung disorder and who do not need breathing support. In these newborns, pneumothorax is often found by accident, and these infants may not need any treatment. However, sometimes a spontaneous pneumothorax can be life-threatening, and some newborns who have a spontaneous pneumothorax develop another lung disorder called persistent pulmonary hypertension. Doctors closely monitor all infants with pneumothorax.
Other air-leak syndromes
Other air-leak syndromes include the following:
Pneumomediastinum
Pulmonary interstitial emphysema (air in the tissues of the lungs between the air sacs)
Pneumopericardium (air in the sac around the heart)
Pneumoperitoneum (air in the abdominal cavity)
Subcutaneous emphysema (air under the skin)
Air that leaks from the lungs into the tissues in the center of the chest is called pneumomediastinum. Unlike pneumothorax, this condition usually does not affect breathing and does not require treatment. Pneumomediastinum is usually only discovered when the infant has a chest x-ray for an unrelated issue.
Pneumopericardium and pneumoperitoneum are medical emergencies.
Pulmonary interstitial emphysema may require changes in positioning, or specialized ventilation techniques.
Subcutaneous emphysema is rare and often a complication of other air-leak syndromes. It often goes away on its own and rarely requires additional treatment.
Symptoms of Pneumothorax in the Newborn
Pneumothorax in the newborn sometimes causes no symptoms. However, it typically causes rapid and labored breathing. Newborns also may grunt when breathing out and may have a bluish color to their skin and/or lips (cyanosis). In newborns with dark skin, the skin may appear blue, gray, or whitish, and these changes may be more easily seen in the mucous membranes lining the inside of the mouth, nose, and eyelids.
The chest on the affected side is larger than the unaffected side.
Diagnosis of Pneumothorax in the Newborn
Transillumination
Chest x-ray
Doctors suspect pneumothorax in newborns who develop worsening trouble breathing. When examining these newborns, doctors may notice diminished sounds of air entering and leaving the lung on the side of the pneumothorax.
Doctors sometimes place a fiberoptic light against the affected side of the newborn’s chest while in a darkened room (transillumination). The light shines through the newborn's thin chest wall and can show pockets of air in the space around the lungs. Transillumination is often not helpful in larger babies.
A chest x-ray confirms the diagnosis of pneumothorax in the newborn.
Treatment of Pneumothorax in the Newborn
Oxygen
Sometimes removal of air from the chest cavity
No treatment is needed for newborns who do not have symptoms and who have a small pneumothorax.
Full-term newborns who have mild symptoms may be placed in a small tent into which oxygen is pumped (an oxygen hood) or receive oxygen via a two-pronged tube placed in the nostrils so that they breathe air that contains more oxygen than the air in the room does. The amount of oxygen given is typically enough to maintain adequate oxygen levels in the blood.
If the newborn’s breathing is labored or if the level of oxygen in the blood declines, and particularly if the circulation of blood is impaired, the air must be rapidly removed from the chest cavity. Air is removed from the chest cavity by using a needle and syringe or by placing a plastic tube into the chest cavity to continuously suction and remove air from it. The tube is removed after doctors make sure no more air will accumulate, usually after several days.
A pneumomediastinum requires no treatment and goes away on its own.
