1. Case Report Tension Pneumatocele Feb. 4 th, 2005 R1 Su, H.C.

2. Male G3P3 C/S at 30 wks Feb. 19 th, 2004 1640 gm 7.6 kg

3. 1 st Admission: Ward High fever Respiratory failure CT arranged

4. Sudden onset of severe tachypnea on Jan. 9 th, 2005

5. Physical Examination Jugular veins Breath sounds Heart sounds

6. 2 Days Passed Dyspnea Progressive subcutaneous emphysema

7. Multiple Smaller Ones Compressed pulmonary parenchyma Compressed pulmonary parenchyma

8. Recurrence ! It’s Tension Pneumatocele !

9. NimbexNimbex SCCSCC IsofluraneIsoflurane KetaminKetamin Induction, keep spontaneous ventilation. Induction, Failed intubation x 2 Catheters inserted Failed intubation x 1 Laryngospasm, SpO 2 droped to 60%. Laryngospasm, Paralyzed, SpO 2 returned to 80%. Paralyzed, SpO 2 > 90%, Surgery proceeded. SpO 2 > 90%, Surgery proceeded. What Happened During Induction ?

10. About the Surgery Left decubitus position Posterolateral thoracotomy Bullaes LLL lobectomy

11. Pneumatocele Necrotizing Pneumonia Necrotizing Pneumonia

12. Necrotizing Pneumonia Invasive pneumonia + necrotic foci Abscess Bronchopulmonary fistula Parapneumonic effusion Rare in childhood Synonyms: pulmonary gangrene Surgery is often required

13. Thin-walled, gas-filled cysts Sequela of pneumonia 1 week to 6 weeks Check-valve Antibiotic Pneumatocele

14. Complications of Pneumatocele Tension pneumatocele Pneumothorax Secondarily infected pneumatocele

15. Bullae? Pneumatocele ?

16. What Can We Do in Tension Pneumatocele ?

17. Outlines Algorithm Early Intervention Operative Treatment

18. A 1m/o, markedly hypoxic, high risk for open surgery management Under fluoroscopic guidance Guidewire through an 18-gauge needle into the pneumatocele; dilatation of the tract followed. 5-Fr pigtail catheter inserted with Pleur-Evac Decompression of pneumatocele in a neonate by percutaneous catheter placement (Case Reports) Kogutt et al. Pediatr Radiol 29: 488-489, 1999

19. Management of Tension Pneumatocele With High-Frequency Oscillatory Ventilation (Case Reports) Hsiu-Nien Shen et al. Chest 121: 284-286, 2002 3 y/o girl with pneumonia, intubated with CMV Massive air leak via chest tube + persistence of poor oxygenation CMV may predispose her to enlarging pneumatocele and airleak HFOV initiated Condition improved

20. Treatment of pneumothorax in newborns: Use of venous catheter versus chest tube Arda et al. Pediatr Int 44: 78-82, 2002 72 newborn patients divided into 2 groups Chest tube versus 18-gauge catheter Shorter duration of the procedure Lower complication rate A safe alternative, particularly useful for newborn

21. What Do We Learn From This Case? Tension Pneumatoceles, Multiple Unsatisfactory Oxygenation Blind Insertion of Multiple Catheters Little Risk of Myocardium Stab Life-saving Technique

22. Necrotizing Pneumonia in Children. Hacimustafaoglu et al. Acta paediatr 93: 1172-1177, 2004 Management of Complicated Pneumatocele. DiBardino et al. J Thorac Cardiovasc Surg 126: 859-861, 2003 Decompression of Pneumatocele in a Neonate by Percutaneous Catheter Placement. Kogutt et al. Pediatr Radiol 29: 488-489, 1999 Management of Tension Pneumatocele With High-Frequency Oscillatory Ventilation. Hsiu-Nien Shen et al. Chest 121: 284-286, 2002 Treatment of Pneumothorax in Newborns: Use of Venous Catheter versus Chest Tube. Arda et al. Pediatr Int 44: 78-82, 2002

23. Thanks for your attention Questions & Answers Questions & Answers