Retained surfactant catheter and pneumothorax in a premature neonate

1 Introduction

Surfactant catheters are used to administer exogenous surfactant as a preventive and therapeutic measure for surfactant deficiency in premature neonates. Complications related to surfactant catheter administration may be life threatening. We describe the case of a retained surfactant catheter in a 700 g premature neonate with associated pneumothorax.

2 Case description

A 3-day old 700-g twin neonate born prematurely at 28 weeks of gestation was transferred for respiratory failure and suspicion of a foreign body on chest X-ray after surfactant administration. The patient was delivered via cesarean section due to placental abruption at a community hospital. Surfactant had been given prior to transfer via a catheter through an endotracheal tube. The endotracheal tube was subsequently removed and oxygen was delivered by using a high flow nasal cannula system. An urgent chest radiography showed a radio-opaque foreign body in the right mainstem bronchus extending to the right hemidiaphragm (Fig. 1). A computerized tomography scan to rule out any associated injuries revealed a tubular structure in the right mainstem bronchus, extending into the right lower lobe, and a small right-sided pneumothorax (Fig. 2). Anesthesia was induced intravenously with maintenance of spontaneous ventilation. Direct laryngoscopy and rigid bronchoscopy with oxygen insufflation was performed by the surgeon after applying topical local anesthesia to the vocal cords. Good visualization of the foreign body (an 8- Fr suction catheter) was obtained and a fractured tube was removed with a grasping forceps via a 1.1 mm bronchoscope. Simultaneously, a chest tube was expeditiously inserted by the surgeon with relief of an expanding pneumothorax. At the conclusion of the procedure the patient was transferred to the neonatal intensive care unit, hemodynamically stable, intubated and sedated. An ipsilateral second chest tube was placed in the neonatal intensive care unit the following day, because of a persistent air leak. Both chest tubes were removed at the 19th and 20th days postoperatively, and the patient was extubated on the 30th day. There was no related problems reported in the follow up visits.

3 Discussion

Airway obstruction with a foreign body is extremely rare in neonates, and presents unique challenges. Older children tend to aspirate toys and food related items, however, airway obstruction from a foreign body in hospitalized neonates are likely from medical devices [1]. Removal of foreign bodies from the airway is challenging and life threatening at any age, especially in a premature newborn of low birth weight (<1000 g). Management goals include adequate ventilation while minimizing inspired oxygen concentration and peak inspiratory pressures and preservation of hemodynamic stability with avoidance of risk factors for intraventricular hemorrhage.

Several physiological considerations are to be taken into consideration. The premature, low birth weight neonate is at greater risk of cardiovascular collapse during anesthesia and surgery than the full-term neonate. Cardiac output depends more on heart rate and the high resting heart rate does not permit an increase in cardiac output to the same extent as a full term neonate [2]. Increased pulmonary vascular resistance predisposes to right-to-left shunting that worsens with hypoxia, hypercarbia and acidosis. Partial occlusion of the small diameter airway from secretions, foreign body, and loss of muscle tone increases the work of breathing, while low lung volumes and poor compliance increase intrapulmonary shunt and ventilation/perfusion mismatch with increased risk of hypoxia, hypercarbia and acidosis. Biphasic ventilatory response to hypoxia and a decreased response to hypercapnia, in low birth premature neonates would result in apneic episodes with acute decompensation. Preventing of hypothermia is crucial, by applying an underbody Bair Hugger device, heating pads, warming the room and covering the patient as much as possible. Possible complications such as pneumothorax, bleeding, inability to remove the broken catheter translaryngeally and complete airway obstruction should be prepared for and discussed. Maintenance of spontaneous respiration versus lung ventilation in the presence of a pneumothorax and airway narrowing are both challenging in a small weight premature neonate with a greater risk of cardiovascular collapse. Performing a laryngoscopy with the patient awake may be risky because of potential increase in intracranial pressure and intraventricular hemorrhage [3], episodes of breath holding and movement of the patient.

Avoiding the risk of uncontrolled displacement of the foreign body by coughing is important to avoid total occlusion of the airways, laryngospasm and/or bronchospasm, tracheobronchial laceration, bleeding and failed bronchoscopy requiring urgent thoracotomy. Efficient communication between the different teams involved and team readiness is essential.

Pneumothorax without retention of a suction tube as a complication following surfactant application and as a complication of a closed-tube endotracheal suction catheter has been described [4, 5]. Surfactant is considered as one of the most important treatments of respiratory distress syndrome in the premature newborn. Different modalities for surfactant administration have been described, with the ideal method of its administration remaining not well determined. The tracheal intubation, surfactant administration and tracheal extubation method is proven to work but is invasive. A small trial with laryngeal mask airway surfactant administration in preterm >1200 g with established respiratory distress syndrome, compared to no treatment [6], showed a short term effect in reducing oxygen requirements with no significant difference in subsequent mechanical ventilation and endotracheal surfactant administration, pneumothorax, days on intermittent positive airway pressure or oxygen supplementation. Also, a small study reported no significant difference between nebulized surfactant administration compared to no treatment groups in chronic lung disease or other outcomes, such as oxygenation 1 to 12 hours after randomization, need or duration for mechanical ventilation, continuous positive airways pressure or supplemental oxygen administration. No side effects of the nebulized surfactant therapy, or aerosol inhalation were reported [7]. More recently, a meta-narrative review of the efficacy and safety of minimally invasive surfactant administration using a thin catheter, aerosolization, a laryngeal mask airway, and pharyngeal administration in preterm infants with or at risk for respiratory distress syndrome, showed, in two randomized studies of surfactant, no significant difference in the outcome of bronchopulmonary dysplasia but a potential reduction in the need for mechanical ventilation within 72 hours of birth when compared with standard care [8]. The use of endotracheal catheters provided comparable results to the tracheal intubation/surfactant administration/tracheal extubation method regarding mortality and bronchopulmonary dysplasia, with a limited evidence on the comparative efficacy of laryngeal mask airway surfactant administration [9].

Airway obstruction with a foreign body is extremely rare in neonates, is likely from medical devices and presents unique challenges. Complications related to surfactant catheter administration may be life threatening.

Consent for publication

A written consent is obtained.

Funding

None.