Diffuse persistent pulmonary interstitial emphysema secondary to mechanical ventilation in bronchiolitis

Abstract

BackgroundPersistent interstitial pulmonary emphysema (PIE) is a rare disease and it is even more uncommon in full-term infants, like our patient. When conservative management is not successful, surgical treatment should be considered. In our case, ECMO support was iniciated to keep the patient ventilated in order to allow the lung to heal using lung protection strategies.Case presentationWe report an 18-day-old male infant with bronchiolitis that required mechanical ventilation with high positive airway pressures due to severe respiratory insufficiency. Chest X-rays and computed tomography scan revealed a severely hyperinflated left lung with extensive destructive changes and multiple small bullae. These findings were consistent with diffuse persistent interstitial emphysema (PIE), probably due to mechanical ventilation. The patient required high frequency oscillatory ventilation, inotropic support and continuous renal replacement therapy. He eventually suffered a cardiac arrest that required cardiopulmonary resuscitation and ECMO during 5 days with progressive clinical improvement and normalization of the X-ray.ConclusionWe present a patient with diffuse persistent interstitial emphysema who, despite an unfavorable evolution with different mechanical ventilation strategies, had a good response after ECMO assistance.

Selective lung ventilation in the management of unilateral pulmonary interstitial emphysema

“…To achieve better results, selective intubation should be maintained for at least 48 h, and in some cases reaching up to 15 or 20 days. [3][4][5]9 In the case presented the duration of right bronchial intubation was 14 days with gradual improvement of PIE pattern.…”

“…7 PIE differential diagnosis includes both acquired and congenital conditions such as neonatal pneumonia, congenital lobar emphysema, bronchogenic cyst or lymphangiectasia. 4 As demonstrated in the case report, the management of unilateral PIE can be challenging due to the risk of hyperinflammation of the affected lung and atelectasis of the contralateral side. Numerous procedures have been described over the years including conservative measures such as kinesiotherapy and postural drainage which could lead to effective resolution in more localised forms of PIE.…”

“…High-frequency ventilation and extracorporeal membrane oxygenation are thought to be effective in more severe cases, while resection of the affected lobe has been used in unstable newborns with persistent conditions. [3][4][5][6]8 Selective intubation has been described as the most effective non-surgical technique. In this case, right bronchial intubation was easy to achieve by inserting the tube 2 cm further, followed by a chest X-ray confirming correct placement.…”

“…The long-term adverse effects include atelectasis of the upper lobe, hypoventilation and bronchial injury such as scarring and stenosis. 1,4,5 PIE incidence has fallen over the years but remains an important complication, especially in preterm infants. In this paper, we described a successful approach of unilateral pulmonary emphysema with selective ventilation which allowed for complete reabsorption, preventing the use of more invasive techniques.…”

“…[1][2][3] PIE treatment can range from conservative measures and selective unilateral ventilation to high-frequency ventilation, extracorporeal membrane oxygenation or lobectomy in severe cases. [1][2][3][4][5]…”