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Pneumothorax and Air leak syndromes in the newborn: a cohort study

Presented at the Neonatal Society 2010 Spring Meeting.

Ali H, Aldridge L, Esampalli S, Lal M

Neonatal Unit, James Cook University Hospital, Middlesbrough, UK

Background: Pneumothorax is a common complication in the premature newborn with respiratory distress syndrome. It is widely reported in neonatal research as an important morbidity associated with adverse health outcomes (1). The reported incidence of pneumothorax had declined since antenatal corticosteroids and surfactant therapy became standards of care (2). Vastly improved survival in the extreme premature infants has also coincided with widespread use of non-invasive respiratory support in neonatal units. Clinicians are concerned that use of continuous positive pressure (CPAP) may be associated with increases risk of Pneumothorax (3)

Aim: The purpose of this study was to describe the demographic profile of premature infants with pneumothorax in a single tertiary centre cohort. 

Methods: Retrospective, single unit, cohort study. Setting: Regional tertiary neonatal centre providing intensive care within the Northern region and neighbouring neonatal networks. All newborns with pneumothorax or other air leak syndromes over 10 year period from January 2000 to December 2009 were included using neonatal database, discharge summaries and hospital coding system to ensure 100% case ascertainment. Variables examined for association with severity of air leak included gestation, uptake of antenatal steroids, sue of postnatal surfactant and non-invasive respiratory support (CPAP). All relevant demographic data were collected including gender, birth weight, prolonged rupture of membranes, chorioamnionitis, place of birth, mode of delivery, use of muscle relaxants and neonatal transport. Data were analyzed by SPSS statistical software and tested for statistical significance using chi square test.

Results: Of 3804 admissions, 107 infants were diagnosed with pneumothorax or other air leak syndrome (overall incidence of 2.8%). This included 72 premature infants of whom 37 were under 28 weeks gestation. The incidence of pneumothorax and pulmonary interstitial emphysema (PIE) was 2.3% and 0.47% respectively. Most (60%) of pneumothoraces required drainage. There was statistically significant association between the severity of pneumothorax and degree of prematurity, use of surfactant and CPAP. Severe pneumothorax requiring drainage was more in extremely premature infants who didn’t received optimal dose of surfactant (n=11/31 p=0.03). No statistically significant effect was noted with variables such as lack of antenatal steroids, gender, mode of delivery, use of muscle relaxants and squad retrievals. Mortality before discharge in infants under 28 weeks gestation with pneumothorax or air leak was 30%. Similar proportion had intraventricular haemorrhage in this group.

Conclusion: Incidence of pneumothorax and other air leak syndromes was lower compared with other cohort studies. Risk of pneumothorax was increased with use of CPAP and suboptimal surfactant dose, especially in infants under 28 weeks gestation. Effect of CPAP in extreme premature newborns without antenatal steroids and postnatal surfactant exposure require further evaluation.

References
1. Laptook AR et al. (2005). Pediatrics 115 pp 673-80
2. M Whit Walker et al (2002). Perinatology 22 pp 641-5
3. Morley CJ, Davies PG et al. (2008) N Engl J Med. 358(7) pp 700-8

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