Indian Pediatrics 2003; 40:325-328 

Which Patients are at Risk? Evaluation of the Morbidity and Mortality in Newborn Pneumothorax

 

Zekeriya Ilçe, Gökhan Gündogdu, Cem Kara, Barboros Ilikkan*,
Sinan Celayir

From the Departments of Pediatric Surgery and Pediatrics*, Cerrahpasa Medical Faculty, University of Istanbul, Turkey.

Correspondence to: Dr. Sinan Celayir, Associate Professor of Pediatric Surgery, Sakaci Sokak, Mehmet Sayman Apt. No.77, Daire: 8, 81090, Kazasker - Kadiköy, Istanbul, Turkey.

E-mail: scelayir@istanbul.edu.tr

Manuscript received: August 6, 2002; Initial review completed: October 23, 2002;

Revision accepted: November 12, 2002.

This study was conducted to evaluate the morbidity and mortality among the newborns hospitalized for pneumothorax. The data of 83 cases were analysed retrospectively according to gestational age, weight, underlying primary lung pathology, age of admittance, side of pneumothorax, drainage time, need for mechanical ventilation and mortality. Male: Female ratio was 1.6:1. Mean duration of admission was 63.8 hours (2 hours-20 days). 51 patients (61.4%) weighed les than 2500g and 41 patients (49.4%) were preterms. The mean weight was 2280 g (640-5170). Fifty one patients (61.4%) needed mechanical ventilation. The pnemothorax was on the right in 44 (53%), left in 21 (25.7%) and bilateral in 18 patients (21.7%). Overall 32 babies died. Among the non-survivors, 22 (68%) were preterm and there was a defined underlying lung pathology in 24 (75%). Twenty nine (90.6%) of them needed mechanical ventilation. The difference in mortality was significant in the presence of primary lung disease, low birth weight, prematurity and use of mechanical ventilation (P <0.005).

Key words: Morbidity, Mortality, Neonate, Pneumothorax.

Pneumothorax (PN) is not a frequent problem in newborn intensive care units. Newborns with asymptomatic PN consists 1% of cases admitted to the unit and this rate is even lower in cases with symptomatic cases(1-3). However, the mortality and morbidity is high when the PN is not dignosed and treated in time. It is suggested that there is an underlying pulmonary pathology in most of the cases with pneumothorax(3-6). Also, new-born pneumothorax is a frequent condition in artificially ventilated neonates(2,7,8) and the frequency of PN with unknown etiology is unexpectedly high(9,10).

The aim of this retrospective study is to analyse patients with newborn pneumothorax, who were treated with thoracic drainage in the surgical newborn intensive care unit.

Subjects and Methods

A total of 83 cases of neonatal pneumo-thorax treated and followed up in last five years (1996-2001) were studied from aspects of complaint on admission, gestational age, weight, underlying primary lung disease, site of pneumothorax, need of mechanical ventilation, type and duration of drainage, duration of hospitalization and association of these with mortality. For drainage procedure 8-10 Fr tube or pleurocan were used. For definite diagnosis of PN, thorax X-ray was used. For the differential diagnosis from congenital abnormalities, computerized tomo-graphy (CT) was done. Asymptomatic cases without thoracic drainage were not enrolled in the study.

Results

Of the 83 cases, there were 51 male and 32 female neonates. Age ranged between 2 hours and 20 days (mean 63.8 hours). Fifty one (61.4%) of the cases were low birth weight (<2500 g), 41 (49.4%) were pre-mature, 40 (48.2%) term, 2 (2.4%) were post-term. Mean weight of the cases was 2280 g (640-5170 g). Oxygen was supplied with head box temporarily in most of the cases. Mechanical ventilation was applied to 51 (61.4%) of the cases. Pneumothorax was on the right side in 44 (53%), on the left side in 21 (25.3%) and bilateral in 18 (21.7%) of the cases. While in 49 (59%) of the cases an underlying pathology was detected, in 34 (41%) the cause of PN couldn’t be detected. Among the 32 (38.6%) patients who died, PN was on the right side in 12 (37.5%), on the left side in 7 (21.8%) and bilateral in 13 (40.7%). 23 patients (71.8%) were low birth weight, 22 (68.7%) premature; an underlying primary lung disease was present in 24 (75%) and mechanical ventilation was applied to 29 (90.6%). The mean drainage duration was 7.5 days (1-23 days) and the mean hospital stay was 12.6 days (1-64). The duration of thoracic drainage was 2-17 days (mean 5.3 days) in survived cases and 1 to 23 days (mean 9.7 days) in cases died. The primary lung disease was respiratory distress syndrome (RDS) in 19 (62.7%), meconium aspiration (MAS) in 8 (9.6%), congenital pneumonia in 7 (8.4%), nosocomial pneumonia + RDS in 7 (8.4), congenital pneumonia + RDS in 4 (4.8%), RDS + pulmonary hemorrhage in 2 (2.4%) and pulmonary hypertension + RDS in 2 (2.4%) of the patients. While the difference between mortality and side of pneumothorax was not statistically significant, the differ-ences between mortality and presence of underlying pulmonary disease, low birth weight, prematurity and ventilation treat- ment were statistically significant (P <0.005). Factors affecting survival are summarized in Table I.

Table I

Neonatal Pneumothorax and Patient Factors [n(%)] Affecting Survival

	Total n = 83	Survival n = 51	Exitus n = 32
Gestation
Term	42 (50,6)	32 (62.7)	10(31.2)
Preterm*	41(49.4)	19(37.2)	22(68.8)
Side
Right	44(53.0)	32(62.7)	12(37.5)
Left	21(25.3)	14(27.5)	7(21.9)
Bilateral	18(21.7)	5( 9.8)	13(40.6)
Weight
>2500 g	32(38.6)	23(45.1)	9(28.2)
<2500 g	51(61.4)	28(54.9)	23(71.8)
Ventilated*
Yes	51(61.4)	22(43.1)	29(90.6)
Primary lung
pathology*	49(59.0)	25(49.0)	24(75.0)
Idiopathic	34(41.0)	26(51.0)	8(25.0)

* P <0.005.

Figures in parentheses indicate percentages

Discussion

The newborn pneumothorax develops usually secondary to underlying pulmonary pathology and mechanical ventilation and fatal when not treated or delayed in treat-ment(2,11). Newborn pneumothorax is seen more frequently in male, premature and postmature babies(1-3,12). Morbidity and mortality is higher in prematures and in cases with primary pulmonary disease than matures and ones with idiopathic pneumothorax(3,12). The underlying primary pulmonary disease observed are almost nonsurgical pathologies as in this study group. Besides we found similar findings in regard to the distribution as the main group of the patients were low birth weight and mechanical ventilation was applied to 61.4%.

While the mean duration of drainage was 5.3 days in survived cases, it was 9.7 days in cases died. This difference is suggested to be due to early recovery and less need of mechanical ventilation in survived cases. Pro-longed mechanical ventilation and contem-porary drainage increased the hospital stay.

PN cases without any detected cause is rather high. However, the most frequent underlying pulmonary diseases are MAS, RDS and pulmonary infections. We detected no surgical pathology as an underlying cause in our group. But it should be kept in mind that cystic adenoid malformation and pulmonary cysts can be misdiagnosed as pneumothorax and when closed under water thoracic drainage is applied to these cases it may be fatal(4).

Our data suggest, that in new born pneumothorax, low birth weight, pematurity, mechanical ventilation and underlying primary lung disease increase the mortality. Thus the patients having these risk factors should be followed more carefully.

Contributors: All authors were involved in designing the study, collecting the data and writing the manuscript. SC shall act as guarantor for the study.

Funding: None.

Competing interests: None stated.

 References