P1081 - Expanding Pneumatocele Management in an Extremely Low Birthweight Premature Infant

Introduction
There are multiple forms of pulmonary anomalies that can be observed in neonates, such as pneumatoceles. Pneumatoceles are gas-filled cysts that can develop within the lung tissue. The incidence of pneumatoceles in the neonatal population is quite low at approximately 1.8% with no guidelines on how to manage pneumatoceles in the extremely low birthweight (ELBW) premature infant. The etiology of pneumatoceles has been attributed to mechanical ventilation and development of pulmonary interstitial emphysema (PIE) or as a complication of bacterial pneumonia. We present a case illustrating the clinical course and management of an ELBW infant with a persistent, large right sided pneumatocele.

Case Report
This female infant, twin A of mono-di twin gestation, was born via Cesarean section to a 29 year-old gravida 1 para 1 mother at 24+5 weeks gestation due to severe pre-eclampsia refractory to interventions. Prenatal course was otherwise uncomplicated. The mother completed a course of antenatal steroids prior to delivery. The infant’s birth weight was 500 grams and Apgar scores were 6 and 8 at 1 and 5 minutes, respectively. In the NICU, the infant was intubated, placed on high frequency oscillatory ventilation (HFOV), and treated with surfactant. On day of life (DOL) 18, the infant experienced several significant desaturation episodes and chest radiographs revealed a tubular radiolucency overlying the right hemithorax. On subsequent daily chest radiographs, the right lung lucency increased in size concerning for an expanding pneumatocele. On DOL 32 the pneumatocele continued to expand while on HFOV with subsequent hemodynamic compromise despite maximizing medical therapy. Given continued decompensation, the 880 then gram infant underwent right thoracotomy with a pigtail catheter placed into the right lower lobe pneumatocele. After surgical intervention she immediately improved clinically and the pneumatocele gradually decreased in size until it was no longer evident by chest radiograph (DOL 99). The infant continued to improve and was discharged home, on low flow oxygen, on DOL 151.

Discussion
Our approach of maximizing non-surgical support was based on the limited literature available, patient’s weight, and enlarging pneumatocele. However, once the infant further clinically declined to the point of requiring increased ventilatory and vasoactive support secondary to mass effect from the rapidly expanding pneumatocele, the decision was made to surgically intervene on the pneumatocele.

Conclusion
Amongst the literature reviewed, this appears to be the first reported case of a pneumatocele successfully treated by surgical intervention in an infant less than 1,000 grams. This unique case may help providers assess whether or not ELBW infants are potential candidates for surgical intervention, recognize the signs of a hemodynamically significant pneumatocele, and demonstrates that surgical intervention can safely address the sequela of a severe pneumatocele.