(Chest. 2002;121:284-286.)
© 2002
American College of Chest Physicians
Management of Tension Pneumatocele With High- Frequency Oscillatory Ventilation*
Hsiu-Nien Shen, MD;
Frank Leigh Lu, MD;
Huey-Dong Wu, MD;
Chong-Jen Yu, MD, PhD, FCCP and
Pan-Chyr Yang, MD, PhD, FCCP
*
From the Departments of Internal Medicine and Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
Correspondence to: Chong-Jen Yu, MD, PhD, FCCP, Department of Internal Medicine, National Taiwan University Hospital, No. 7 Chung-Shan South Rd, Taipei, Taiwan 100; e-mail: jeffery{at}ha.mc.ntu.edu.tw
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Abstract
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We report the successful application of high-frequency oscillatory
ventilation in a patient with tension pneumatocele (TP). The proposed
check-valve mechanism for the development of pneumatoceles predicts
that positive-pressure ventilation could lead to distension of these
airspaces and formation of TPs. Therefore, high-frequency ventilation
could be more applicable in conditions, such as massive air leak due to
bronchopleural fistula, that are difficult to manage by conventional
ventilator modes.
Key Words: bronchopleural fistula • high-frequency oscillatory ventilation • pneumatocele • Streptococcus pneumoniae
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Introduction
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We
present a case of severe pneumonia, enlarging pneumatoceles, and
pneumothorax in a patient receiving conventional mechanical ventilation
(CMV). Pneumatoceles decreased after the application of
high-frequency oscillatory ventilation (HFOV).
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Case Report
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A 3-year-old girl had a temperature of up to 40°C, cough, and
rhinorrhea. She had had no history of specific medical illnesses. Four
days after initial symptoms appeared, poor appetite, hyperpnea, and
dyspnea developed. She was then admitted to a hospital. A chest
radiograph (CXR) on the first day disclosed right upper lobe (RUL)
pneumonia and pleural effusion (Fig 1
, top left). A normal WBC count (5,900/µL) with severe left
shift (39% band form) was noted. Empirical antibiotics were
administered, but the symptoms still progressed. Disseminated
intravascular coagulation was suspected by thrombocytopenia and
coagulopathy. Hypotension and hypoxemia developed soon after.
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Figure 1.. Top left: CXR on day
1 showed RUL pneumonia and pleural effusion. Top right:
CXR on day 5 disclosed multiple pneumatoceles bilaterally, especially
on the right side. Bottom, left: CXR on
day 11 (day 2 of HFOV) showed the overinflated lungs and a large
pneumatocele on the RUL; pneumothorax was present on the right side.
Bottom right: CXR on day 24 (day 15 of HFOV) showed the
resolution of pneumonia and pneumatoceles.
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She was intubated, and treatment with inotropic medications was
initiated, along with ventilatory support with time-cycled pressure
control. A throat swab culture, blood culture, and pleural fluid
studies were performed. Results of these microbiological studies showed
positive pneumococcal antigen in the pleural effusion. Culture findings
from all other sites were negative. A chest tube was inserted due to
the clinical diagnosis of complicated parapneumonic effusion; pleural
effusion data included WBC, 1,512/µL; and lactate dehydrogenase,
1,779 U/L. Antibiotics were switched to ceftriaxone, erythromycin, and
vancomycin on the next day.
In the days that followed, hemodynamics and oxygenation became
stabilized, yet fever and leukocytosis persisted. Serial CXRs revealed
RUL consolidation with multiple, progressively enlarging pneumatoceles.
One week later, the chest tube was removed, but pneumothorax on the
same side developed thereafter (Fig 1
, top right). After
reinsertion of a new chest tube, massive air leak was noted.
Low-pressure suction (10 cm H2O) through the
chest tube was applied. On the next day (day 9 of hospitalization), she
was transferred to our hospital. On hospital admission, she appeared
lethargic and confused. Her body weight was 12 kg. Vital signs were as
follows: body temperature, 38°C; heart rate, 160 beats/min; BP, 94/76
mm Hg; and respiratory rate (RR), 30 breaths/min. The patient received
time-cycled pressure control ventilation, with settings of peak
inspiratory pressure at 30 cm H2O; flow rate, 25
L/min; peak end-expiratory pressure, 4 cm H2O;
RR, 30 breaths/min, and fraction of inspired oxygen
(FIO2), 100%. Oxygen
saturation, as measured by pulse oximetry, was 88.6%. Chest
examinations revealed persistent air leak from the chest tube on the
right side. Rales and rhonchi were audible. The edge of the liver was 3
cm below the right costal margin. All other data were unremarkable.
Laboratory studies revealed marked leukocytosis (WBC, 43,730/µL) and
a slightly elevated aminotransferase level. The rest of the laboratory
study results were within normal limits. Arterial blood gas levels are
shown in Table 1
.
On day 10, because of massive air leak and persistence of poor
oxygenation with CMV, HFOV (model 3100A; SensorMedics; Yorba Linda, CA)
was applied. Initial settings were as follows: amplitude, 47 cm
H2O, with visible vibrations of the chest wall;
frequency, 10 Hz; flow rate, 28 L/min, inspiratory/expiratory ratio,
0.33; and FIO2, 80%. Mean airway
pressure (MAP) was raised up to 25.5 cm H2O where
the hemodynamics remained stable and the improvement in oxygenation
reached a plateau (Fig 2
). Improvement of the air leak was noted. After the clinical condition
and oxygenation became stable, MAP was reduced gradually to the lowest
acceptable level where a sudden drop of oxygenation occurred with
further reduction in MAP. While MAP was lowered from 25 cm
H2O on day 11 (day 2 of HFOV) to 14 cm
H2O on day 14 (day 5 of HFOV), the size of RUL
pneumatocele decreased on serial CXRs (Fig 1
, bottom left
and bottom right). However, fever, leukocytosis, and mild
air leak persisted. Nevertheless, weaning of HFOV proceeded without
difficulty. After the patient was withdrawn from sedation and
paralysis, spontaneous breathing during HFOV was allowed, since the
airway pressure, vital signs, and blood gas data were relatively
stable. During the course, treatment with antibiotics was partially
modified, with a switch from ceftriaxone to cefotaxime on day 12
because of jaundice and gallbladder sludge on abdominal
ultrasonography. Erythromycin was administered for 2 weeks. Cefotaxime
was replaced by piperacillin sodium/tazobactam sodium on day
21 for suspected drug fever. On day 24 (day 15 of HFOV), ventilatory
support was shifted from HFOV to a T piece, and after 2 h of an
external T-piece trial, she was extubated uneventfully. Meanwhile,
treatment with piperacillin sodium/tazobactam sodium was discontinued
on day 25, and fluconazole was added on day 28 for superimposed
candidal infection of the thoracostomy wound. Vancomycin was
administered for a course of 30 days. General conditions improved
gradually with good oxygenation with room air breathing, though mild
tachydyspnea still persisted. An air leak remained until day 34 when
the chest tube was removed after temporary clamping. A follow-up CXR
showed marked improvement without evidence of pneumatoceles. The
patient was discharged on day 39.
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Discussion
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Pulmonary pneumatoceles are thin-walled, air-containing spaces
that have been recognized as a possible complication of pneumonia with
various infectious etiologies.1
2
Among the bacterial
agents, Staphylococcus aureus is the most commonly
implicated.1
On the other hand, Streptococcus
pneumoniae is rarely reported as a cause of
pneumatoceles.3
Postinfectious pneumatoceles usually
appear within the first week of pneumonia and disappear in an average
of 6 weeks.1
3
Complications of pneumatoceles included secondary infection and
enlargement with tension formation.4
The latter could
cause cardiopulmonary instability by itself. In some instances,
it could subsequently rupture with pneumothorax or lead to the
formation of bronchopleural fistula (BPF), especially during
positive-pressure ventilation.2
4
5
As in the case
presented, the initial use of CMV might have predisposed a patient to
the enlargement of pneumatoceles, with subsequent rupture and prolonged
air leak.
The proposed check-valve mechanism suggests that mechanical ventilation
with positive airway pressure could lead to distension of these
spaces.6
Once tension occurs, the principle of
management is similar to that for pneumothorax. Emergent
decompression is thus indicated. There have been several case reports
of percutaneous decompression of tension pneumatocele (TP) by needle
aspiration,5
catheter drainage,2
4
or chest
tube drainage5
under CT or fluoroscopic guidance. Surgical
pneumonostomy with subsequent pulmonary resection has also been
reported.7
In the present case report, surgery was initially considered in
managing the complicated pulmonary conditions during the early course
of treatment. However, it was not recommended, since extensive
debridement might compromise residual lung function. On the other hand,
initial unstable conditions prohibited the transportation to facilities
for further radiologic-guided procedures.
Persistent air leak during mechanical ventilation is a serious
complication of ventilator therapy. In critically ill patients, the
loss of a substantial portion of inspired tidal volume through BPF may
significantly alter the intrapulmonary distribution of ventilation,
ventilation-perfusion matching, and arterial blood gases. Several
techniques have been used to decrease air loss through BPF, promote
closure, and maintain good gas exchange.8
High-frequency
ventilation is one of these procedures.8
9
The rationales
for its use are to decrease airway pressure, reduce risk of barotrauma,
and improve ventilation/perfusion matching and gas
exchange.8
As noted in this case, we switched ventilator
mode from CMV to HFOV. Not only did TP not enlarge, it further
decreased in size with the reduction of MAP and amplitude. This
observation supported the proposed mechanism of HFOV in patients with
TP.
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Footnotes
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Abbreviations: BPF = bronchopleural fistula; CMV =
conventional mechanical ventilation; CXR = chest radiograph;
FIO2 = fraction of inspired oxygen;
HFOV = high-frequency oscillatory ventilation; MAP = mean airway
pressure; RR = respiratory rate; RUL = right upper lobe;
TP = tension pneumatocele
Received for publication November 6, 2000.
Accepted for publication June 1, 2001.
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References
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Sewall, LE, Franco, AI, Wojtowycz, MM, et al (1993) Pneumatoceles causing respiratory compromise: treatment by percutaneous decompression. Chest 103,1266-1267[Abstract/Free Full Text]
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Donnelly, LF, Klosterman, LA (1998) Cavitary necrosis complicating pneumonia in children: sequential findings on chest radiography. AJR Am J Roentgenol 171,253-256[Abstract/Free Full Text]
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Zuhdi, MK, Spear, RM, Worthen, HM, et al (1996) Percutaneous catheter drainage of tension pneumatocele, secondarily infected pneumatocele, and lung abscess in children. Crit Care Med 24,330-333[CrossRef][ISI][Medline]
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McGarry, T, Giosa, R, Rohman, M, et al (1987) Pneumatocele formation in adult pneumonia. Chest 92,717-720[Abstract/Free Full Text]
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Caffey, D (1940) Regional obstructive pulmonary emphysema in infants and children. Am J Dis Child 60,586-605
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Wu, MH, Tseng, YL, Lin, MY, et al (1997) Surgical treatment of pediatric lung abscess. Pediatr Surg Int 12,293-295[ISI][Medline]
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Coghill, CH, Haywood, JL, Chatburn, RL, et al (1991) Neonatal and pediatric high-frequency ventilation: principles and practice. Respir Care 36,596-612
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TOP
Abstract
Introduction
