April 1978 The Journal o f P E D I A T R I C S
633
Pneumothorax: A complication of endotracheal tube suctioning Russell S. Vaughan, M.D.,
Buffalo, N.
Y., James A. Menke, M.D.,*
S p r i n g f i e l d , IlL, and George P. Giacoia, M . D . , B u f f a l o , N. Y.
T H E U SE o f positive p r e s s u r e v e n t i l a t i o n a n d c o n t i n u o u s positive a i r w a y p r e s s u r e in t h e t r e a t m e n t o f i d i o p a t h i c r e s p i r a t o r y distress s y n d r o m e in t h e n e o n a t e h a s led to a n i n c r e a s e in the i n c i d e n c e o f p n e u m o t h o r a c e s c a u s e d by alveolar r u p t u r e I ~ r e s u l t i n g f r o m t h e h i g h p r e s s u r e s n e e d e d to ventilate n o n c o m p l i a n t lungs. R e c e n t l y A n d e r son and Chandra 3 have reported another cause of pneum o t h o r a x in sick n e o n a t e s r e c e i v i n g artificial ventilation: p e r f o r a t i o n o f the lung b y s u c t i o n catheters. T h e p u r p o s e o f this r e p o r t is to a d d two f u r t h e r e x a m p l e s o f this complication.
CASE REPORTS Case 1. Baby B was a 1,590 gm infant transferred to Buffalo Children's Hospital RICN because o f RDS and prematurity. At 48 hours of life the infant required ventilatory assistance and at 51 hours he developed a large right pneumothorax. A chest tube was inserted, with complete re-expansion of the right lung. At 72 hours he developed a left pneumothorax, again successfully treated with tube thoracostomy. On day7, immediately following suctioning of the endotracheal tube, the infant had a prolonged episode of bradycardia. The nurse noted that the suction catheter] passed 22 cm down the nasotracheal tube. A radio-opaque catheter was then inserted down the tube the same distance and a chest radiograph (Fig. 1) was obtained; the catheter was felt to be in the right pleura! space. The infant was treated conservatively with chest tube drainage and increased negative pressure as high as 50 cm of water. He was subsequently weaned off the ventilator on day 10, off CPAP on day 15, and extubated successfully on
From the Department of Pediatrics, State University of New York at Buffalo, and Buffalo Children "s Hospital. *Reprint address: St. John's Hospital, 800 E. Carpenter St., Springfield IL 62702.
day 16. The left chest tube was removed on day 17 and the right chest tube was successfully removed on day 34. He has since been discharged from the hospital and is doing well. Case 2. Baby C was a 1,020 gm twin , A " infant transported to the Buffalo Children's Hospital RICN on a ventilator because of RDS and prematurity. At 24 hours of life he became dusky and had bradycardia following suctioning of the endotracheal tube; transillumination suggested, and a chest radiograph confirmed, the presence of a right tension pneumothorax. A chest tube was placed and the lung was fully re-expanded. Over the next four Abbreviations used CPAP: continuous positive airway pressure RDS: idiopathic respiratory distress syndrome RICN: Regional Intensive Care Nursery days, despite an adequately functioning chest tube and negative Pressures as high as 50 cm of water, the patient had repeated reaccumulation of air in the right pleural cavity. While suctioning, a nurse noted that the suction catheter* passed twice the normal distance down the nasotracheal tube. A No. 3V2 Fr. radioopaque catheter was inserted gently down the nasotracheal tube as far as the suction catheter had been introduced and a chest radiograph was obtained (Fig. 2); the catheter was felt to be in the fight pleural space. Over the next four days the infant had several episodes of reaccumulation of air. The chest tube was removed on day 25 with immediate recurrence of the pneumothorax, requiring repeat tube thoracostomy and drainage. The chest tube was successfully removed on day 32. He was weaned from the respirator on day 49 and extubated on day 59. The remainder of the hospital course was unremarkable. DISCUSSION B o t h o f o u r p a t i e n t s p r e s e n t e d with p n e u m o t h o r a c e s p r i o r to the d i s c o v e r y o f t h e p e r f o r a t i o n s . A l t h o u g h w e c a n n o t rule out a b r o n c h o p l e u r a l fistula u n r e l a t e d to the
~No. 8 Fr Argyle Flo-Tr01 Suction Catheter, Sherwood Medical, Braunswich Inc., St. Louis, MO (catheters used once, then discarded).
*No. 6 Fr. Argyle Flo-Trol Suction Catheter, Sherwood Medical, Braunswich Inc., St. Louis, MO.
0022-3476/78/0492-0633500.20/0 9 1978The C..V. M o s b y C o .
Vol. 92, No. 4, pp. 633-634
634
Vaughan, Menke, and Giacoia
The Journal of Pediatrics April 1978
Fig. 1. Chest roentgenogram of Patient B in the lateral position following placement of the radio-opaque catheter. Arrows demonstrate the position of the catheter.
Fig. 2. Anteroposterior chest of Patient C obtained after the radio-opaque catheter had been placed. The position of the catheter is noted by the arrow..
suction catheter, we feel this to be an unlikely possibility. In two of the three infants previously reported '~ with a similar condition, surgery was needed to control the leak. In the third, the infant died, and the perforations were noted at autopsy. In view of their experience in those three cases, the authors performed a postmortem study which showed that a catheter, when passed down an endotracheal tube, enters the right lower lobe bronchus more than 80% of the time, as presumably occurred i n o u r two patients. They were also able to cause perforations in 14 of 17 infants when the catheter was "placed through the endotracheal tube and advanced as far as possible.,'3
at autopsy, oral-carinal and nasocarinal distances and have related these distances to weight. By using their data, an estimation of the ,distance to the carina may be obtained by knowing the patient's weight. The individual suctioning the infant can safely introduce the suction catheter only 1 to 2 cm beyond the carina. Limiting the distance when introducing a suction catheter through an endotracheal tube may lessen the risk of perforation and resultant pneumothorax.
Endotracheal suctioning is, therefore, a procedure with significant attendant risks aside from those that result from changes in compliance and atelectasis. Gregory 4 has detailed a method for catheter suctioning through endotracheal tubes. He stated that the suction catheter should be introduced as far into the airway as possible without using force, and the catheter should then be withdrawn 0.5 cm before suction is applied. In view of the previous report and our 6wn experience, we feel that this technique may be hazardous to infants. Anderson and Chandra 3 and Coldiron'~have measured,
REFERENCES
1~ Hall R, and Rhodes P: Pneumothorax and pneumomediastinum in infants with idiopathic respiratory distress syndrome receiving continuous positive airway pressure, Pediatrics 55:493, 1975. 2. Ogata ED, Gregory CA, Kitterman JA, Phibbs RH, and Tooley WH: Pneumothorax in the respiratory distress syndrome: Incidence and effect on vital signs, blood gases and pH, Pediatrics 58:177, 1976. 3. Anderson KD, and Chandra R: Pneumothorax secondary to perforation of sequential bronchi by suction catheters, J Pediatr Surg 11:687, 1976. 4. GregoryGA: Respiratory care of newborn infants, Pediatr Clin North Am 19:311, 1972. 5. Coldiron JS: Estimation of nasotracheal tube length in neonates, Pediatrics 41:823, 1968.
633
Pneumothorax: A complication of endotracheal tube suctioning Russell S. Vaughan, M.D.,
Buffalo, N.
Y., James A. Menke, M.D.,*
S p r i n g f i e l d , IlL, and George P. Giacoia, M . D . , B u f f a l o , N. Y.
T H E U SE o f positive p r e s s u r e v e n t i l a t i o n a n d c o n t i n u o u s positive a i r w a y p r e s s u r e in t h e t r e a t m e n t o f i d i o p a t h i c r e s p i r a t o r y distress s y n d r o m e in t h e n e o n a t e h a s led to a n i n c r e a s e in the i n c i d e n c e o f p n e u m o t h o r a c e s c a u s e d by alveolar r u p t u r e I ~ r e s u l t i n g f r o m t h e h i g h p r e s s u r e s n e e d e d to ventilate n o n c o m p l i a n t lungs. R e c e n t l y A n d e r son and Chandra 3 have reported another cause of pneum o t h o r a x in sick n e o n a t e s r e c e i v i n g artificial ventilation: p e r f o r a t i o n o f the lung b y s u c t i o n catheters. T h e p u r p o s e o f this r e p o r t is to a d d two f u r t h e r e x a m p l e s o f this complication.
CASE REPORTS Case 1. Baby B was a 1,590 gm infant transferred to Buffalo Children's Hospital RICN because o f RDS and prematurity. At 48 hours of life the infant required ventilatory assistance and at 51 hours he developed a large right pneumothorax. A chest tube was inserted, with complete re-expansion of the right lung. At 72 hours he developed a left pneumothorax, again successfully treated with tube thoracostomy. On day7, immediately following suctioning of the endotracheal tube, the infant had a prolonged episode of bradycardia. The nurse noted that the suction catheter] passed 22 cm down the nasotracheal tube. A radio-opaque catheter was then inserted down the tube the same distance and a chest radiograph (Fig. 1) was obtained; the catheter was felt to be in the right pleura! space. The infant was treated conservatively with chest tube drainage and increased negative pressure as high as 50 cm of water. He was subsequently weaned off the ventilator on day 10, off CPAP on day 15, and extubated successfully on
From the Department of Pediatrics, State University of New York at Buffalo, and Buffalo Children "s Hospital. *Reprint address: St. John's Hospital, 800 E. Carpenter St., Springfield IL 62702.
day 16. The left chest tube was removed on day 17 and the right chest tube was successfully removed on day 34. He has since been discharged from the hospital and is doing well. Case 2. Baby C was a 1,020 gm twin , A " infant transported to the Buffalo Children's Hospital RICN on a ventilator because of RDS and prematurity. At 24 hours of life he became dusky and had bradycardia following suctioning of the endotracheal tube; transillumination suggested, and a chest radiograph confirmed, the presence of a right tension pneumothorax. A chest tube was placed and the lung was fully re-expanded. Over the next four Abbreviations used CPAP: continuous positive airway pressure RDS: idiopathic respiratory distress syndrome RICN: Regional Intensive Care Nursery days, despite an adequately functioning chest tube and negative Pressures as high as 50 cm of water, the patient had repeated reaccumulation of air in the right pleural cavity. While suctioning, a nurse noted that the suction catheter* passed twice the normal distance down the nasotracheal tube. A No. 3V2 Fr. radioopaque catheter was inserted gently down the nasotracheal tube as far as the suction catheter had been introduced and a chest radiograph was obtained (Fig. 2); the catheter was felt to be in the fight pleural space. Over the next four days the infant had several episodes of reaccumulation of air. The chest tube was removed on day 25 with immediate recurrence of the pneumothorax, requiring repeat tube thoracostomy and drainage. The chest tube was successfully removed on day 32. He was weaned from the respirator on day 49 and extubated on day 59. The remainder of the hospital course was unremarkable. DISCUSSION B o t h o f o u r p a t i e n t s p r e s e n t e d with p n e u m o t h o r a c e s p r i o r to the d i s c o v e r y o f t h e p e r f o r a t i o n s . A l t h o u g h w e c a n n o t rule out a b r o n c h o p l e u r a l fistula u n r e l a t e d to the
~No. 8 Fr Argyle Flo-Tr01 Suction Catheter, Sherwood Medical, Braunswich Inc., St. Louis, MO (catheters used once, then discarded).
*No. 6 Fr. Argyle Flo-Trol Suction Catheter, Sherwood Medical, Braunswich Inc., St. Louis, MO.
0022-3476/78/0492-0633500.20/0 9 1978The C..V. M o s b y C o .
Vol. 92, No. 4, pp. 633-634
634
Vaughan, Menke, and Giacoia
The Journal of Pediatrics April 1978
Fig. 1. Chest roentgenogram of Patient B in the lateral position following placement of the radio-opaque catheter. Arrows demonstrate the position of the catheter.
Fig. 2. Anteroposterior chest of Patient C obtained after the radio-opaque catheter had been placed. The position of the catheter is noted by the arrow..
suction catheter, we feel this to be an unlikely possibility. In two of the three infants previously reported '~ with a similar condition, surgery was needed to control the leak. In the third, the infant died, and the perforations were noted at autopsy. In view of their experience in those three cases, the authors performed a postmortem study which showed that a catheter, when passed down an endotracheal tube, enters the right lower lobe bronchus more than 80% of the time, as presumably occurred i n o u r two patients. They were also able to cause perforations in 14 of 17 infants when the catheter was "placed through the endotracheal tube and advanced as far as possible.,'3
at autopsy, oral-carinal and nasocarinal distances and have related these distances to weight. By using their data, an estimation of the ,distance to the carina may be obtained by knowing the patient's weight. The individual suctioning the infant can safely introduce the suction catheter only 1 to 2 cm beyond the carina. Limiting the distance when introducing a suction catheter through an endotracheal tube may lessen the risk of perforation and resultant pneumothorax.
Endotracheal suctioning is, therefore, a procedure with significant attendant risks aside from those that result from changes in compliance and atelectasis. Gregory 4 has detailed a method for catheter suctioning through endotracheal tubes. He stated that the suction catheter should be introduced as far into the airway as possible without using force, and the catheter should then be withdrawn 0.5 cm before suction is applied. In view of the previous report and our 6wn experience, we feel that this technique may be hazardous to infants. Anderson and Chandra 3 and Coldiron'~have measured,
REFERENCES
1~ Hall R, and Rhodes P: Pneumothorax and pneumomediastinum in infants with idiopathic respiratory distress syndrome receiving continuous positive airway pressure, Pediatrics 55:493, 1975. 2. Ogata ED, Gregory CA, Kitterman JA, Phibbs RH, and Tooley WH: Pneumothorax in the respiratory distress syndrome: Incidence and effect on vital signs, blood gases and pH, Pediatrics 58:177, 1976. 3. Anderson KD, and Chandra R: Pneumothorax secondary to perforation of sequential bronchi by suction catheters, J Pediatr Surg 11:687, 1976. 4. GregoryGA: Respiratory care of newborn infants, Pediatr Clin North Am 19:311, 1972. 5. Coldiron JS: Estimation of nasotracheal tube length in neonates, Pediatrics 41:823, 1968.
