THE ORIGINAL "ON CALL PROBLEM" CONCEPT STARTED WITH NEONATOLOGY
In 1988 the first edition of NEONATOLOGY Dr. Tricia Gomella presented the concept of the "ON CALL PROBLEM". The goal was to provide a practical approach to common problems in the NICU and to serve as an effective teaching tool. This pioneering "ON CALL" problem solving concept approach has been replicated across numerous specialties and many other publications. Here is an example from the 8th Edition of GOMELLA'S NEONATOLOGY: Eye Discharge and Conjunctivitis.
SAMPLE ON CALL PROBLEM FROM
8th Edition GOMELLA’S NEONATOLOGY
On Call Problem: Eye Discharge and Conjunctivitis
I. Problem. A purulent eye discharge is noted in a 3-day-old infant.Eye discharge in a neonate is usually caused by neonatal conjunctivitis (also known as ophthalmia neonatorum) or congenital nasolacrimal duct obstruction (CNLDO or congenital dacryostenosis). Neonatal conjunctivitis (conjunctivitis occurring within the first 4 weeks of life) is an inflammation of the surface or covering of the eye that presents with eye discharge and hyperemia. It is the most common ocular disease in neonates. Etiology is chemical, bacterial, or viral. Most infections are acquired during vaginal delivery, but ascending infection can occur. In the United States, the incidence of infectious conjunctivitis is 1% to 2%, and in the world, it is 0.9% to 21%. Neonates with conjunctivitis require a thorough clinical and appropriate laboratory evaluation so appropriate treatment can be started as soon as possible if necessary. CNLDO is a membranous obstruction at the valve of Hasner, which is at the distal end of the nasolacrimal duct. Incidence is 6% to 20% in infants (studies show higher incidence in preterm infants when compared to full-term infants). The symptoms are persistent tearing and a mucoid discharge in the inner corner of the eye.
II. Immediate questions
A. How old is the infant? Age may be helpful in determining the cause of eye discharge, noting that bacterial infections can occur anytime.
1. First day of life. Conjunctivitis is most often due to ocular prophylaxis secondary to medications such as silver nitrate drops, tetracycline, erythromycin, gentamicin, povidone iodine solution, and chloramphenicol.
2. 2 to 5 days old. Conjunctivitis is most often due to Neisseria gonorrhoeae (but can present earlier with premature rupture of membranes).
3. 5 to 12 days old. Conjunctivitis is most often due to Chlamydia trachomatis. It is usually seen during this time and can present as late as the second or third week.
4. 5 to 14 days old. Conjunctivitis is often due to other bacterial microbes. This includes pathogens from the skin, respiratory, gastrointestinal, or vaginal tract. See Table 58–3.
5. 5 to 28 days old. Pseudomonas aeruginosa infections are typical during this time.
6. 6 to 14 days old. Conjunctivitis can be due to herpes simplex virus (HSV).
7. 2 weeks old. CNLDO usually manifests at 2 weeks of age but can sometimes be seen in the first few days to the first few weeks after birth.
B. Is the discharge unilateral or bilateral? Typical symptoms are persistent tearing and a mucoid discharge in the inner corner of the eye.
1. Unilateral conjunctivitis is most often seen with Staphylococcus aureus, P aeruginosa, HSV, and adenovirus.
2. Bilateral conjunctivitis is seen with infection caused by N gonorrhoeae or by the use of ocular prophylaxis.
3. Unilateral, then bilateral. Chlamydia usually develops in 1 eye but affects the other after 2 to 7 days. Lacrimal duct obstruction usually causes unilateral discharge, but up to 20% of infants have bilateral obstruction.
C. What are the characteristics of the discharge (eg, purulent, serous, greenish)?
1. Purulent discharge: More common with bacterial infection. Gonorrhea has a classic profuse purulent discharge.
2. Serous discharge: More common with a viral infection.
3. Greenish discharge: More characteristic of P aeruginosa.
4. Serosanguinous (light/pale red) discharge: Watery with a mixture of serum and blood can be seen with herpes conjunctivitis. Nonpurulent discharge can also be seen with herpes.
5. Watery early, purulent later (may be blood stained): Chlamydial infection.
6. Watery tears or mucus or yellow discharge in eye: CLNLDO can cause watery tears in the corner of the eye or tears draining from the eyelid down the cheek. It can also cause mucus or yellowish discharge in the eye.
D. Did the infant receive eye prophylaxis, and was it properly given? Ocular prophylaxis against gonococcal ophthalmia neonatorum is used to prevent gonorrheal infection (prevent blindness), and certain prophylactic agents (silver nitrate, povidone-iodine, and erythromycin) prevent nongonococcal and nonchlamydial conjunctivitis during the first 2 weeks of life. The majority of medical groups recommend prophylactic ocular topical medication for all newborns for the prevention of gonococcal ophthalmia neonatorum (Table 58–1). Various conjunctivitis prophylactic regimens are presented in Table 58–2. Infants can still get gonococcal conjunctivitis with prophylaxis, but the risk drops from 50% to 2%. Gonorrheal ophthalmia neonatorum prophylaxis is mandatory in the United States but may not be in other countries (eg, Denmark, Norway, Sweden, Great Britian, Belgium, Australia, The Netherlands). A reevaluation of the mandatory prophylaxis is being considered by the American Academy of Pediatrics (AAP) because of improved prenatal screening, testing at the time of delivery, and maternal treatment to prevent exposure to the neonate, especially in areas where the maternal infection is low. There is concern that some strains of gonorrhea have shown resistance to erythromycin. (See Table 58-1 and 58-2 at end of chapter)
1. Proper ocular administration technique is as follows: Give shortly after birth or within 1 hour of birth (to facilitate parent–infant bonding), whether cesarean or vaginal delivery.
a. For the term infant, wipe each eyelid with sterile cotton or gauze; instill the prophylactic agent (single-dose tubes or ampules preferred, 1-cm ribbon of ointment or 2 drops of solution) in each of the lower conjunctival sacs. Massage the eyelids gently to spread the agent. Wipe away any excess ointment after 1 minute. Do not irrigate or flush the eyes.
b. For the very premature infant with fused eyes, apply the prophylactic agent without separating the eyelids.
2. Agents used for prophylaxis: 0.5% erythromycin ophthalmic ointment, 2.5% povidone-iodine solution, 1% silver nitrate solution, and 1% tetracycline ophthalmic ointment.
a. 0.5% erythromycin ophthalmic ointment. A 1-cm ribbon is given in each eye. AAP, Centers for Disease Control and Prevention (CDC), and US Preventive Services Task Force (USPSTF) recommend only erythromycin ophthalmic ointment for prophylaxis, and it is the only approved agent in the United States. It causes less chemical conjunctivitis than other agents such as silver nitrate. There is some concern for N gonorrhoeae strains being resistant to erythromycin.
b. 1% silver nitrate solution. This is recommended over erythromycin if the patient population has a high number of penicillinase-producing N gonorrhoeae. It is highly irritating and frequently causes a chemical conjunctivitis (see later in chapter). It is not available in the United States but is used elsewhere. The World Health Organization (WHO) recommends 2 drops in each eye.
c. 1% tetracycline ophthalmic ointment is as effective as silver nitrate but is not available in the United States.
d. 2.5% povidone-iodine ophthalmic solution (water based; do not use alcohol-based solution) is widely available, low cost, and effective. It is used in developing countries and is not available in the United States. Some data suggest that povidone-iodine is more effective against C trachomatis than silver nitrate or erythromycin. There are 3 doses available (5%, 2.5%, and 1.25%); 5% is used for preoperative use. The 2.5% solution is most commonly used. Note: Use the ophthalmic solution and not the detergent version of povidone-iodine, which can damage the cornea.
e. Other topical agents that have been used when erythromycin is not available. Recommended backup agents per the AAP Red Book include the following:
i. Use first: Azithromycin ophthalmic solution 1%; 1 to 2 drops are placed in each conjunctival sac. Note this is not an ointment but a solution, so care must be used when placing these drops. CDC recommendations for this medication: 2 people are required to administer this medication. One person holds the lids open, while the other instills the drops.
ii. Use second: Either gentamicin ophthalmic ointment 0.3% or tobramycin ophthalmic ointment 3%.
iii. Use last: Ciprofloxacin ophthalmic ointment 0.3% is generally not recommended because of high gonococcal resistance.
f. Fatty acid–based formulas (monocaprin and myristoleic acid), which are bactericidal against virulent bacteria and effective against S aureus, are being studied for prevention of ophthalmia neonatorum.
3. Society and organization recommendations for ophthalmic neonatorum prophylaxis can be found in Table 58–1 at end of chapter.
E. Does the mother have a history of sexually transmitted infections? Infants who pass through the birth canal of an infected mother with gonorrhea or chlamydia have an increased conjunctivitis risk. Neonatal conjunctivitis is frequently diagnosed in infants born to human immunodeficiency virus (HIV)-infected mothers.
F. Is the infant at high risk?
1. Conjunctivitis. Neonates are at increased risk for conjunctivitis and more serious cases of conjunctivitis because of decreased tear production, lack of immunoglobulin A (IgA) in tears, decreased immune function, absence of lymphoid tissue of the conjunctiva, and decreased lysozyme activity. Risk factors may include mode of delivery, exposure of the infant to infectious organisms, no or inadequate prophylaxis after birth, ocular trauma/local eye injury during delivery, poor hygienic conditions, premature rupture of membranes, prolonged delivery, prematurity, mechanical ventilation, increased birthweight, history of midwife interference, HIV-infected mother, poor prenatal care, documented or suspected sexually transmitted infection, infection after delivery from direct contact from health care worker, or aerosolization. Performing red reflex examinations increases the rate of neonatal conjunctivitis.
2. Congenital nasolacrimal duct obstruction. Neonates are at an increased risk for CNLDO if they have Down syndrome, Goldenhar sequence, clefting syndromes, any midline facial anomaly, hemifacial microsomia, or craniosynostosis.
G. Is the infant low birthweight and low gestational age? An infant with conjunctivitis who has a low birthweight and low gestational age has a higher risk of having a conjunctivitis caused by a gram-negative organism (Klebsiella spp., Escherichia coli, Serratia marcescens, P aeruginosa, and Enterobacter spp.). Premature infants have an increased risk of CNLDO.
III. Differential diagnosis. As noted, eye discharge in the neonate most commonly is caused by conjunctivitis (chemical/inflammatory, bacterial, or viral) or is due to an obstruction (CNLDO). Other less common diagnoses that may cause an eye discharge in an infant are foreign body, orbital or preseptal cellulitis, entropion, trichiasis, eye trauma (corneal abrasion following delivery), dacryocystitis, infectious keratitis, subconjunctival hemorrhage (breakage of vessels during delivery), vitreous hemorrhage (associated with thrombocytopenia and polycythemia), congenital anomalies of the nasolacrimal system, corneal epithelial disease, neonatal abstinence syndrome (lacrimation), and congenital glaucoma. Common causes of infectious and noninfectious conjunctivitis can be found in Table 58–3 (See end of Chapter)
A. Chemical/inflammatory conjunctivitis. Usually secondary to silver nitrate ocular drops (causes a transient chemical conjunctivitis in 50%–90% of infants) and is the most common cause of conjunctivitis in underdeveloped countries. The incidence of chemical/inflammatory conjunctivitis has decreased in the United States since silver nitrate drops are no longer being used. Chemical conjunctivitis can occur from all the other prophylactic ocular antibiotics but less often. It is a nonpurulent inflammation of the eye with a watery discharge, conjunctival injection, and swelling within several hours of instilling the medication. The conjunctivitis shows a maximum inflammatory response around 48 hours and usually clears by the third or fourth day.
B. Infectious conjunctivitis. (See Table 58–3 at end of chapter.) Infectious conjunctivitis in the newborn is caused by either a bacteria or virus.
1. Mechanisms of infection
a. Infections acquired through an infected maternal genital tract during birth are typically N gonorrhoeae, C trachomatis, group B streptococci, or HSV. They tend to reflect sexually transmitted infections in the community. Any bacteria that are normally present in the vagina (not sexually transmitted) can also cause neonatal conjunctivitis.
b. Cesarean section can be associated with ascending infections through ruptured or intact amniotic membranes (transplacental or transmembrane transmission). Risk factors include amniotic fluid leak, vaginal examinations, and use of internal monitors.
c. Postnatally acquired infections from organisms that are present in the environment (normal skin flora or nasopharyngeal flora). Infection can occur through direct contact, by contamination of parent’s or caregiver’s hands or mouth, or respiratory tract spread. Examples are S aureus (coagulase negative most common in one study), Staphylococcus epidermidis, Streptococcus spp., Pseudomonas spp., Serratia spp., Klebsiella spp., and Enterococcus spp. Pseudomonas infections are more typical in hospitalized preemies beyond 5 days of birth.
2. Chlamydial (inclusion) conjunctivitis. Most common cause of ophthalmia neonatorum transmitted from the mother and develops in 20% to 50% of infants delivered vaginally to infected untreated mothers. Topical prophylaxis with erythromycin does not prevent the incidence of chlamydial ophthalmia neonatorum. Prophylaxis does not eradicate nasopharyngeal colonization or pneumonia. Infected eyes have a mucopurulent discharge, ocular congestion, and eyelid swelling; membranes form on the palpebral conjunctiva, and there is no follicular response. Infection can be unilateral or bilateral and usually starts out as a watery discharge that becomes purulent and copious later. Corneal opacification, chemosis (thickened conjunctivae), and pseudomembranes may be present. Pneumonia is present in 10% to 20% of infants with chlamydial conjunctivitis. Otitis, pharyngeal, and rectal colonization can occur. Repeated and chronic infections of C trachomatis can cause trachoma (rare in the United States), which is a chronic follicular keratoconjunctivitis that causes scarring and neovascularization of the cornea that can result in blindness.
3. Gonococcal conjunctivitis. Second most commonly reported communicable disease and is the most feared cause of neonatal conjunctivitis. Approximately 28% of infants born to women with gonorrheal disease in the United States will develop gonococcal ophthalmia neonatorum. It accounts for <1% of neonatal ophthalmia in the United States and is most commonly transmitted from the mother during vaginal birth. The transmission rate from an infected mother to her newborn is up to 50%. Ocular manifestations tend to occur 3 to 5 days after birth with abrupt onset. Usually bilateral, the eyes are very red (hyperacute conjunctivitis) with a thick, purulent drainage and swelling. The lid has chemosis (edema), and a conjunctival membrane may be present. This is an emergency because, left untreated, it can cause a corneal ulcer and perforation within hours. The incidence is low because of prophylactic ocular treatment immediately after birth. Infants can manifest systemic manifestations, including sepsis, meningitis, arthritis, vaginitis, and urethritis.
4. Pseudomonas conjunctivitis. A nosocomial infection that used to be rare but is becoming more common in nurseries. It presents with a purulent discharge, eyelid edema and erythema, and pannus formation. It can lead to a devastating and rapid corneal ulceration and perforation, blindness, endophthalmitis, and death. The organism thrives in moisture-filled environments such as respiratory equipment, and infection occurs most often in hospitalized premature infants or those with depressed immunity. It can be responsible for an epidemic conjunctivitis in premature infants. Infants with Pseudomonas conjunctivitis can have systemic complications (sepsis/meningitis).
5. Herpes simplex keratoconjunctivitis. There are 3 different types of presentation of herpes in the neonate. The one that will be discussed here is disease localized to the skin, eyes, or mouth (SEM disease). HSV type 2 (HSV-2) can cause unilateral or bilateral conjunctivitis (especially keratoconjunctivitis), optic neuritis, chorioretinitis, cataracts encephalitis, and permanent vision impairment and is the most frequent viral cause of conjunctivitis. The conjunctivitis can be superficial or may involve the deeper layers of the cornea; vesicles may appear on the nearby skin (80% of infants with SEM have skin vesicles). The infants can have lid edema, conjunctival injection, and a watery nonpurulent discharge. A conjunctival membrane may be present. Most of these infections are secondary to HSV-2 sexually transmitted infection (maternal genital tract ascending infection, through the birth canal, or by transplacental mechanisms); 15% to 20% are caused by HSV-1. Suspect herpes if the conjunctivitis is not responding to antibiotic therapy. Most neonatal HSV-1 infections are related to contact with someone with an active infection (fever blister or cold sore) in the perinatal period.
6. Viral causes (other than herpes). Infection usually occurs through direct contact, through contamination of the hands, or via respiratory tract spread. These are usually associated with other symptoms of respiratory tract disease due to adenovirus (most common), Enterovirus, or Parechovirus. There is usually redness, and it is more commonly unilateral. Infants with adenovirus can have petechial hemorrhages. The discharge is usually mild and watery and is rarely purulent. Lymphadenopathy and preauricular adenopathy can be seen in approximately 50% of cases. Epidemic keratoconjunctivitis from adenovirus can occur by direct contact or from equipment during an eye examination. The CDC site states that Zika virus can cause a conjunctivitis when an infant acquires the infection perinatally (from women who become infected within 2 weeks of delivery). Perinatal transmission of chikungunya virus can also cause conjunctivitis.
7. Other bacterial infections (nongonococcal, nonchlamydial). (See Table 58–3.) Conjunctivitis can be caused by other microbial agents (not listed earlier), and these usually present as a milder form of conjunctivitis. There may be conjunctival injection, chemosis, and a discharge. Infections caused by Haemophilus spp. and Streptococcus pneumoniae are associated with dacryocystitis (inflammation of the nasolacrimal sac). Staphylococcal conjunctivitis is usually a nosocomial infection. It is the most frequent isolate but may not be a cause of conjunctivitis in infants who are colonized and can cause mild conjunctival hyperemia. Methicillin-resistant S aureus conjunctivitis can also occur and has been associated with nurseries and NICUs.
C. Congenital nasolacrimal duct obstruction (dacryostenosis) occurs in approximately 5% to 20% of infants. The nasolacrimal duct may fail to canalize completely at birth, and the obstruction is usually at the nasal end of the duct (distal nasolacrimal duct). It is usually unilateral. The symptoms are persistent tearing and a mucoid discharge in the inner corner of the eye. One in 5 infants may have transient discharge (watery and sticky, particularly after sleep) due to a delay in the normal development and opening of the tear duct that resolves spontaneously. CNLDO is the most common of the lacrimal duct anomalies in congenital rubella syndrome. Dacryocystitis is a secondary infection in the lacrimal sac.
A. Physical examination
1. Ophthalmic examination. Examine both eyes/eyelids for swelling and edema, and check the conjunctiva for injection (congestion of blood vessels) and chemosis (conjunctival swelling). A purulent discharge, edema, and erythema of the lids and injection of the conjunctiva are suggestive of bacterial conjunctivitis. Check for ulcerations and the presence of a red reflex.
2. Perform a complete physical examination to rule out signs of respiratory or systemic infection. Evaluate for any adenopathy.
B. Laboratory studies
1. Gram-stained smear of the exudate discharge to check for white blood cells (WBCs) (a sign of infection) and bacteria (to identify the organism). A sample of the discharge should also be submitted for culture and sensitivity testing (chocolate agar and/or Thayer-Martin agar for N gonorrhoeae and blood agar for other bacteria). Typical findings on Gram stain:
a. N gonorrhoeae conjunctivitis. Gram-negative intracellular diplococci (kidney bean shaped) and increased WBCs (neutrophils). Note: A presumptive diagnosis can be made based on the Gram stain, but remember that other nonpathogenic Neisseria species and Moraxella catarrhalis can look like N gonorrhoeae on Gram stain, so it is best to support the diagnosis with a culture.
b. S aureus conjunctivitis. Gram-positive cocci in clusters and WBCs.
c. P aeruginosa conjunctivitis. Gram-negative bacilli and WBCs.
d. Conjunctivitis caused by Haemophilus spp. Gram-negative coccoid rods.
e. Streptococcal or enterococci. Streptococci are gram-positive spherical cocci, and enterococci are gram-positive lancet-shaped encapsulated diplococci.
f. Other gram-positive organisms. S pneumoniae, Streptococcus viridans, S epidermidis, group A and B streptococci, and Corynebacterium species.
g. Other gram-negative organisms. E coli, Klebsiella pneumoniae, S marcescens, Proteus, Enterobacter, H influenzae, Acinetobacter, P aeruginosa, Neisseria cinerea, M catarrhalis, Eikenella corrodens, and Stenotrophomonas maltophilia.
h. Herpes simplex. See lymphocytes, plasma cells, and multinucleated giant cells.
i. C trachomatis. Difficult to stain but classified as gram negative, typically coccoid or rod shaped bacteria. Neutrophils, lymphocytes, and plasma cells.
j. Chemical conjunctivitis. Neutrophils and lymphocytes (occasionally).
k. CNLDO. The Gram stain is negative, or there is normal conjunctival flora unless there is a secondary infection.
2. If a chlamydial infection is suspected, methods to diagnose chlamydia ophthalmia include:
a. Culture identification of the organism (gold standard) by a conjunctival swab specimen with 100% specificity and sensitivity. A result can be obtained after 48 to 72 hours.
b. Nonculture testing
i. Antigen detection methods include direct fluorescent antibody (DFA) and enzyme immunoassay (EIA) tests. DFA is the only US Food and Drug Administration (FDA)-approved nonculture test for chlamydia conjunctivitis in the neonate. An example of one such platform is the commercially available Pathfinder Chlamydia DFA (Bio-Rad Laboratories, Hercules, CA).
ii. Nucleic acid amplification tests, which use a method of amplifying C trachomatis DNA or RNA sequences. Nucleic acid amplification tests (NAATs) are not FDA approved for use in conjunctivitis in infants but can be used if available through a Clinical Laboratory Improvement Amendments–certified laboratory. Some believe that NAAT has higher sensitivity and specificity than the DFA assays and may actually outperform culture results.
c. To obtain the swab specimen, use a Dacron-tipped swab or swab from the manufacturer (do not use calcium alginate or wood shafted swabs) and evert the eyelid; then swab the everted eyelid to obtain conjunctival cells. The exudate is not adequate for the test.
3. If herpes is suspected. Historically a histologic exam of lesions for multinucleated giant cells and eosinophilic intranuclear inclusions was performed (Tzanck smear), but is no longer recommended due to low sensitivity. Recommended test is the cell culture of swab specimens (surface and other), skin vesicles, and cerebrospinal fluid (CSF). HSV polymerase chain reaction (PCR) assay can be done on all the specimens including whole blood sample (a positive result does not mean disseminated disease) but has not been studied in neonates. Rapid diagnostic techniques such as DFA and EIA are available but less sensitive than cultures. A rapid culture test, ELVIS ID HSV test system (Quidel Corporation, San Diego, CA), is available.
4. In gonococcal infection, cell culture is the most widely used test for nongenital sites. NAATs are not FDA approved for N gonorrhoeae testing on nongenital sites.
5. Pseudomonas infection. Suspect based on Gram stain and send culture of the exudate.
C. Imaging and other studies. Imaging tests usually do not have a role in the workup of conjunctivitis but neuroimaging may be done in herpes conjunctivitis.
1. Blot test for nasolacrimal duct obstruction. Apply gentle digital pressure over the lacrimal sac. If there is moisture, it indicates an obstruction. If there is a mucopurulent reflux (positive blot test) from the punctum, this suggests a complete obstruction.
2. Fluorescein dye disappearance test. Best test to rule out CNLDO. Instill 1 drop of 0.5% proparacaine followed by 1 drop of 2% fluorescein/moistened fluorescein strip into the lower conjunctiva of each eye. Wipe away any excess dye. After 5 to 10 minutes, evaluate if any dye is still present. If there is significant dye present in the eye and failure of the dye to appear in the nose after 10 to 15 minutes, then an obstruction may exist. If the dye disappears, then there is no obstruction. Alternatively, dim the room and use a cobalt blue light or Burton lamp to see if the dye is still present.
3. Slit lamp examination with fluorescein staining by an ophthalmologist. Can help differentiate viral versus bacterial conjunctivitis. With viral one can see conjunctival follicles, with bacterial one can see papillae. One will see dendritic keratitis with HSV keratitis.
4. Tests for viral conjunctivitis. Viral cell culture with immunofluorescence assay and PCR. Rapid antigen testing (Adeno Plus, Rapid Pathogen Screening, Inc.) is available for adenovirus.
V. Plan. Complications (perforation of the cornea, blindness, Chlamydia pneumonia, sepsis, meningitis) can be severe, so it is important to treat as soon as possible. Do not wait for the culture results to treat the infant. Send the culture, and based on the Gram stain, start empirical treatment,
A. Important facts in the management of conjunctivitis
1. Infection can spread easily from one eye to another or to other people by touching the eye or drainage. Proper and frequent hand washing and wearing gloves are essential. Isolation is recommended for gonococcal, herpes, and Pseudomonas conjunctivitis. See Appendix F for specific isolation guidelines.
2. Drainage is contagious for 24 to 48 hours after beginning treatment.
3. Irrigate eye with sterile isotonic saline to remove accumulated purulent drainage.
4. Systemic treatment is required for gonococcal, Chlamydia, Pseudomonas, and herpetic conjunctivitis. Some recommend systemic treatment for H influenzae conjunctivitis since it is often associated with otitis media or other severe infections such as sepsis and meningitis. Topical and systemic treatment is recommended for Pseudomonas and herpes infection.
5. Avoid eye patching.
6. Consultation with a pediatric ophthalmologist or pediatric infectious disease specialist should be considered.
7. Evaluate for signs of systemic disease. Infants with conjunctivitis are at risk for secondary infections such as sepsis, meningitis, and pneumonia.
8. Follow daily for signs of improvement or worsening.
9. Breast milk/colostrum to treat conjunctivitis. Colostrum and breast milk contain antimicrobial and anti-inflammatory properties and have been used to treat conjunctivitis or mucopurulent discharge from nasolacrimal duct obstruction. Colostrum is more effective than mature breast milk because it contains leukocytes and has higher concentrations of antibodies, especially IgA. Studies suggest that the use of breast milk or colostrum is safe, has no side effects, and may help as a treatment for blocked tear ducts and that the use of colostrum may be effective against certain type of infections. However, because evidence is limited and studies are conflicting, this treatment is not recommended. Preventive effects of colostrum (2 drops in each eye) against neonatal conjunctivitis have been documented when compared to no prophylaxis.
B. Chemical conjunctivitis. Observation only is needed because this usually resolves within 2 to 4 days. Lubrication with artificial tears (4 times a day) may be helpful.
C. Gonococcal conjunctivitis. This is considered an emergency, as it can result in perforation of the globe, corneal scarring, and blindness. Because of the high prevalence of penicillin-resistant N gonorrhoeae, the treatment is not penicillin but a third-generation cephalosporin (eg, ceftriaxone). Note: Gonococcal conjunctivitis can occur even with appropriate eye prophylaxis in infants delivered to mothers with positive maternal gonococcal infection.
1. Infants with evidence of gonococcal conjunctivitis, scalp abscess, or disseminated infection need to be hospitalized.
2. Isolate the infant during the first 24 hours of parenteral antibiotic therapy. Both mother and partner need full medical examinations and treatment for N gonorrhoeae. Mother cannot visit the baby, breast feed, or room-in until she receives 24 hours of antibiotics.
3. Evaluate for disseminated disease if the infant has gonococcal ophthalmia (arthritis, meningitis, sepsis, scalp abscess caused by scalp electrodes from fetal monitoring). Cultures should include blood, eye discharge, CSF, joint aspirate, and any other sites, as noted earlier. Conjunctival exudates need to be cultured for N gonorrhoeae and tested for antibiotic susceptibility.
4. Tests for concomitant infection with C trachomatis, congenital syphilis, and HIV. The mother and her sexual partner should also be evaluated and presumptively treated for gonorrhea. Check maternal hepatitis B surface antigen results. Do not treat empirically for chlamydia unless the test comes back positive.
5. Parenteral antibiotics. Ceftriaxone is the preferred antibiotic treatment because of the high frequency of penicillin-resistant N gonorrhoeae. Ceftriaxone is not recommended in a neonate with hyperbilirubinemia or in a neonate receiving or planning on receiving calcium-containing intravenous (IV) fluids. Ceftriaxone can displace bilirubin from binding to serum albumin, possibly causing bilirubin encephalopathy. Cefotaxime is recommended in any infant with hyperbilirubinemia and in infants on calcium-containing IV fluids.
6. For uncomplicated gonococcal conjunctivitis (without dissemination), administer a single dose of ceftriaxone 25 to 50 mg/kg IV or intramuscularly (IM) (up to a maximum of 125 mg). WHO recommends 1 of the following: ceftriaxone (50 mg/kg IM single dose [maximum 150 mg]), kanamycin (25 mg/kg IM single dose [maximum 756 mg]), or spectinomycin (25 mg/kg IM single dose [maximum 75 mg]).
7. For gonococcal conjunctivitis with dissemination (arthritis, septicemia) and scalp abscess, ceftriaxone 25 to 50 mg/kg IV or IM may be given once every day for 7 days. An alternative therapy is cefotaxime (recommended for hyperbilirubinemic infants or infants receiving calcium-containing IV fluids) at 25 mg/kg every 12 hours, given IV or IM for 7 days. If meningitis is present, treatment should be given for a total of 10 to 14 days.
8. Healthy infants (no conjunctivitis) born to mothers with untreated or inadequately treated gonococcal infection. These infants are treated with systemic antibiotics because gonococcal ophthalmia or disseminated infection can occur. A single dose of ceftriaxone (25–50 mg/kg IV or IM; not to exceed 125 mg) is given. Topical antimicrobial therapy is not necessary if systemic therapy has been given.
9. Irrigate the eyes with sterile isotonic saline (normal saline) solution immediately and at frequent intervals (every 1–2 hours) to remove mucopurulent discharge until clear. Topical antibiotics are not necessary when systemic antibiotics are used and are only recommended when a corneal ulcer is present. Use topical atropine if there is corneal involvement.
10. Pediatric ophthalmologic consultation is usually requested because gonococcal ophthalmia can lead to corneal perforation and blindness. Infectious disease consultation is usually requested also to help manage the infant.
D. Chlamydial conjunctivitis. Evaluate for systemic disease (pneumonia, otitis, pharyngeal and rectal colonization). Pneumonia has been reported in 20% of infants with chlamydial conjunctivitis.
1. Recommended neonatal prophylaxis does not prevent neonatal chlamydial conjunctivitis, extraocular infection, or nasopharyngeal colonization.
2. Topical treatment with antibiotics is ineffective and unnecessary when systemic therapy is given, but some institutions use erythromycin drops (4 times a day).
3. Oral erythromycin base or ethylsuccinate, 50 mg/kg/d, in 4 divided doses for 14 days by mouth, is recommended. Azithromycin suspension (20 mg/kg/d for 3 days) is an alternative regimen. A second course of erythromycin is sometimes required because approximately 20% of cases recur after therapy because erythromycin is only about 80% effective. Infantile hypertrophic pyloric stenosis (IHPS) has been seen in infants <6 weeks="" old="" especially="" 2="" treated="" with="" erythromycin="" it="" has="" been="" seen="" azithromycin="" but="" the="" risk="" is="" unknown="" these="" infants="" should="" be="" followed="" and="" parents="" counseled="" about="" signs="" of="" ihps="" aap="" still="" recommends="" because="" other="" treatments="" have="" not="" well="" studied="" who="" 20="" mg="" kg="" d="" orally="" 1="" dose="" daily="" for="" 3="" days="" over="" p="">
4. Infants born to mothers with untreated chlamydia are at high risk for infection. Prophylactic antibiotic treatment is not indicated. Monitor for infection. If adequate follow-up is not possible, treatment should be considered.
5. Treat the mother and sexual partner if the infant has C trachomatis infection.
E. Pseudomonas conjunctivitis
1. Isolate the patient and implement standard precautions unless infection is resistant, in which case contact precautions are indicated.
2. Evaluate for systemic disease because superficial infection can progress rapidly to serious systemic infection (sepsis, meningitis). Infants with low birthweight and lower gestational age have an increased risk for systemic disease. Pseudomonas infection can lead to devastating consequences: corneal ulceration and perforation, endophthalmitis, blindness, serious systemic infection, and subsequent death.
3. Parenteral therapy is recommended because Pseudomonas is a virulent organism. Use an aminoglycoside for a minimum of 10 to 14 days. Systemic therapy with an antipseudomonal β-lactam may also be indicated.
4. Topical therapy is required because systemic antibiotics have poor penetration in the eye. Treat with topical therapy for 2 weeks with an aminoglycoside, such as gentamicin ophthalmic ointment or tobramycin ophthalmic ointment/solution. Some will treat with ciprofloxacin ophthalmic ointment/solution because gentamicin and tobramycin can cause a chemical conjunctivitis. See doses in Table 58–4.(End of chapter)
5. Ophthalmology consultation is critical because the infection may be devastating. Infectious disease consult may also be helpful, especially with Pseudomonas meningitis. For Pseudomonas meningitis, careful follow-up is recommended (check for hearing loss, developmental delay, and neurologic abnormalities).
F. Herpes simplex conjunctivitis
1. Isolate the patient and implement contact precautions. Infant can room-in if low risk of infection, and mother can visit and breast feed if there are no vesicular herpetic lesions in the breast area and all lesions are covered.
2. Obtain a complete set of viral cultures (PCR assays on skin and mucus have not been studied in neonates; do this in addition to the gold standard cultures). A positive culture obtained from any of the surface sites >12 to 24 hours after birth is considered positive and not intrapartum exposure contamination.
a. Obtain a surface culture from the mouth, nasopharynx, conjunctivae, and anus for HSV surface culture and HSV PCR assay (if desired). Any positive culture from any surface area >12 to 24 hours after birth indicates viral replication and is suggestive of an infection in the infant and not contamination by intrapartum exposure.
b. Skin vesicle (if present) culture for HSV and PCR assay.
c. Cerebrospinal fluid and whole blood culture for HSV and PCR assay, as clinical findings may be absent in CSF disease early on.
d. Whole blood sample for serum alanine aminotransferase. Can be elevated in HSV hepatitis.
e. Direct fluorescent antibody staining of vesicle scrapings or EIA detection of HSV antigens. These methods are specific but less sensitive than a culture.
3. Administer a topical therapy with ocular herpes simplex virus: 1% trifluridine solution/drops or 0.15% ganciclovir gel (both are proven to be effective) 5 times per day for 10 days (every 2 hours).
4. Parenteral acyclovir for all neonates with herpes simplex virus disease (including conjunctivitis): 60 mg/kg/d IV divided 3 times a day for a minimum of 14 days for SEM disease. If central nervous system (CNS) disease or disseminated disease is present, treat for a minimum of 21 days. (For dosage, see Chapter 155.)
5. Ophthalmologic evaluation and follow up are required for all infants with neonatal HSV disease because chorioretinitis, cataracts, and retinopathy may develop. Infectious disease consultation is also recommended.
6. Neuroimaging should be done for a baseline brain anatomy (magnetic resonance imaging is the most sensitive, but computed tomography or ultrasound is also acceptable). Neurologic follow-up is important.
7. With cerebrospinal fluid involvement, a repeat lumbar puncture (LP) needs to be done near the end of the therapy to document that CSF is negative for HSV DNA on PCR assay; if positive, another week of therapy needs to be given and another repeat LP needs to be done. Parenteral treatment should not be stopped until CSF PCR is negative.
8. Suppression therapy with oral acyclovir (300 mg/m2/dose) 3 times a day for 6 months is recommended following acute neonatal HSV disease. Adjust dose for growth. This prevents skin recurrences and improves neurodevelopmental outcomes in infants with CNS disease. Check absolute neutrophil counts at 2 and 4 weeks after starting therapy and then monthly.
G. Other bacterial infections once gonococcal, chlamydial, and Pseudomonas infections have been ruled out.
1. Local saline irrigation.
2. Topical antibiotics only are usually required. (See Table 58–4.) For gram-positive organisms: bacitracin or erythromycin. For gram-negative organisms: gentamicin, tobramycin, or ciprofloxacin ointment or solution. Ointments are preferred over eye drops for neonates because they have reduced washout effect.
a. Ophthalmic ointment: 0.5- to 1-cm ribbon in each eye every 6 hours for 7 to 14 days.
b. Ophthalmic solution: 1 to 2 drops into each eye every 4 hours for 7 to 14 days.
3. H influenzae infection may require further evaluation of the infant (rule out sepsis, meningitis, and other infections if indicated), and systemic antibiotics may be necessary. Topical conjunctivitis can be treated with any fluoroquinolone topical antibiotic.
4. Methicillin-resistant S aureus conjunctivitis. Treatment depends on the clinical situation; some do not need to be treated. Topical chloramphenicol eye drops and fortified vancomycin drops can be compounded under the direction of an ophthalmologist. See Chapter 141.
5. For gram-negative conjunctivitis in premature low birthweight infants and increasing antibiotic resistance (especially noted among the β-lactam antibiotics), third- and fourth-generation antibiotics are recommended.
6. Viral infections other than herpes simplex conjunctivitis. Treatment of viral conjunctivitis is mainly supportive (artificial tears, cool compresses). It usually resolves without specific treatment. One study found that conjunctival irrigation with 2.5% povidone-iodine was effective for the treatment of adenoviral conjunctivitis (“pink eye”) in infants and reduced the spread of infection.
H. Congenital nasolacrimal duct obstruction is the most common cause of persistent tearing and discharge in infants. Treatment can involve nonsurgical or surgical methods. Nonsurgical treatment consists of observation or digital massage (Crigler massage). Surgical treatment consists of probing the nasolacrimal duct to open the membranous obstruction, nasolacrimal duct stent insertion, balloon catheter dilation, or dacryocystorhinostomy.
1. Observation. Most cases clear spontaneously without treatment. Studies show varying results (66% to 88% to 96% resolution in 6 to 10 months to 1 year). Some physicians will treat with topical antibiotic eye drops to treat the discharge or mattering around the eye.
2. Digital (Crigler) massage. Massaging the inside corner of the eye over the lacrimal sac, in a downward motion with expression toward the nose, can exert hydrostatic pressure on the lower end of the lacrimal duct and may help to open any obstruction and establish patency. The massage method involves 5 to 10 strokes 4 times a day.
3. Nasolacrimal probing. If the problem does not resolve and symptoms persist (usually after 6 months), the infant should be evaluated by an ophthalmologist. Probing of the duct is usually indicated. It can be done as an office procedure or under general anesthesia. Probing will not work if the duct is swollen due to infection or if the obstruction is caused by a bony protrusion of the inferior turbinate. Probing is not without risk of complications, which can include creation of a false passage, injury to the nasolacrimal duct, bleeding, aspiration, and laryngospasm. There is controversy as to when this should be done (early or later). A Cochrane group performed a review to see if immediate probing versus delayed probing resulted in more treatment success. Results noted that the effects of immediate versus deferred probing are uncertain but found that children who had unilateral CNLDO and immediate office probing had a higher success of treatment compared to deferred probing.
4. Nasolacrimal duct stent insertion, balloon catheter tear duct dilation, and dacryocystorhinostomy are reserved for those cases that have failed other procedures.
I. Dacryocystitis. This is an infection of the lacrimal (tear) sac. It is almost always related to nasolacrimal duct obstruction. It can cause redness, swelling, and pain near the nose just below the lower lid.
1. Congenital dacryocystitis is a serious disease that can cause orbital cellulitis, brain abscess, meningitis, sepsis, and death if not treated immediately and aggressively with systemic antibiotics. Urgent ophthalmology consult is necessary.
2. Acquired dacryocystitis can be acute or chronic.
a. Acute dacryocystitis. Sudden onset of redness and edema over the lacrimal sac and may have injection of the conjunctiva and preseptal cellulitis. Orbital cellulitis can also occur, and urgent ophthalmology consultation is recommended. Treatment includes heat, systemic antibiotics, and percutaneous drainage of the abscess.
b. Chronic dacryocystitis. Infant presents with tearing and mattering. Inside the lacrimal sac is a chronic low-grade bacterial infection. Treatment includes dacryocystorhinostomy.
I. Problem. An infant may have a pneumothorax (an abnormal accumulation of air or gas in the pleural space, between the visceral and parietal pleura). It can develop spontaneously or be secondary to trauma. A pneumothorax occurs more often in the neonatal period than any other time in life.
A. Spontaneous pneumothorax
1. Primary spontaneous pneumothorax (PSP). Occurs when there is no obvious precipitating factor, no clear cause, it is idiopathic, without lung disease. Familial spontaneous pneumothorax is a rare cause in neonates.
2. Secondary spontaneous pneumothorax (SSP). Occurs from underlying lung disease (respiratory distress syndrome [RDS], meconium aspiration syndrome [MAS], and others).
B. Traumatic pneumothorax
1. Iatrogenic occurs from an accidental insult during a procedure such as central line placement or thoracentesis.
2. Positive pressure ventilation (mechanical or noninvasive ventilation) can cause barotrauma.
3. Chest trauma can occur when blunt or penetrating trauma occurs to the chest (rare in neonate).
C. Tension pneumothorax. A life-threatening condition that occurs when air is trapped in the pleural cavity under positive pressure. Air goes into the pleural cavity during inspiration, but no air is allowed to escape during expiration. It acts as a 1-way valve. Because air is trapped, intrathoracic positive pressure rises, lung volume decreases, and pressure compresses the mediastinum and causes a shift, with increased pulmonary vascular resistance. This results in an increase in central venous pressure, decrease in venous return to the heart, and a decrease in cardiac output. This causes displacement of mediastinal structures and cardiopulmonary compromise.
D. Persistent pneumothorax. A pneumothorax that persists >7 days in the absence of mechanical problems.
II. Immediate questions
A. Are symptoms of tension pneumothorax present? A tension pneumothorax occurs when air is trapped in the pleural cavity under positive pressure. A tension pneumothorax presents as a medical emergency, and the patient’s status will deteriorate acutely. The following signs may be seen with tension pneumothorax: cyanosis, hypoxia, tachypnea, a sudden decrease in heart rate with bradycardia, a sudden increase in systolic blood pressure followed by narrowing pulse pressure and hypotension, an asymmetric chest (bulging on the affected side), distention of the abdomen (secondary to downward displacement of the diaphragm), decreased breath sounds on the affected side, and shift of the cardiac apical impulse (most consistent finding) away from the affected side. A cyanotic upper half of the body with a pale lower half can be seen.
B. Is the patient asymptomatic? An asymptomatic pneumothorax is present in 1–2% of neonates. It occurs more frequently in males and term and post-term infants. It is usually unilateral. Most of these cases are discovered on chest radiograph at admission. Up to 15% of these infants were meconium stained at birth.
C. Is mechanical ventilation being used? The incidence of pneumothorax in patients receiving positive-pressure ventilation is 15–30%. A life-threatening tension pneumothorax may result from mechanical ventilation.
D. Are there risk factors for a pneumothorax? Neonates delivered between 30 and 36 weeks, moderately preterm, or term by caesarean section have a higher incidence of pneumothorax. The following are associated with an increased risk: male infant, low birthweight, premature, meconium-stained amniotic fluid, vacuum extraction, a low 1-minute Apgar score, ventilator treatment, perinatal asphyxia, cardiopulmonary resuscitation, transient tachypnea, RDS, MAS, pneumonia, pulmonary hypoplasia, urinary tract anomalies, infants who were resuscitated at birth, continuous positive airway pressure, and positive pressure ventilation. a1-Antitrypsin deficiency may play a role in some cases of spontaneous pneumothorax of the newborn.
III. Differential diagnosis. Radiologically, the differential diagnosis can include pneumomediastinum, congenital lobar emphysema, atelectasis with compensatory hyperinflation, congenital diaphragmatic hernia, congenital cystic adenomatoid malformation, and a large pulmonary cyst. Clinically, it can present as any process that causes respiratory distress, and it is important to exclude other causes of respiratory distress in a neonate: RDS, endotracheal tube obstruction/displacement, aspiration, congenital heart disease, asphyxia, congenital diaphragmatic hernia (CDH), congenital cystic adenomatoid malformation (CCAM), or pleural effusions. Suddenrapid deterioration in a neonate can be from a tension pneumothorax, pneumopericardium, or a massive pericardial effusion/cardiac tamponade (umbilical venous catheter).
1. Symptomatic pneumothorax (includes tension vs nontension pneumothorax). Nontension symptoms: irritability, grunting, pallor cyanosis, restlessness, apnea, mild tachypnea, respiratory distress. Tension symptoms are noted in Section II.A previously.
2. Asymptomatic pneumothorax.
3. Persistent pneumothorax.
B. Pneumomediastinum. Air in the mediastinal space that may be confused with a true pneumothorax. On the radiograph, mediastinal air can elevate the lobes of the thymus (called “angel wing” or “spinnaker sail” sign), and the air can also track within the extrapleural space and outline the inferior aspect of the heart (“continuous diaphragm sign”). See Figure 11–19.
C. Congenital lobar emphysema. A rare anomaly of lung development that presents with respiratory distress and pulmonary lobar hyperinflation. Overdistention of one lobe secondary to air trapping occurs most commonly (47–50%) in the left upper lobe. Other lobe involvement is right upper lobe (20%), right middle lobe (28%), and lower lobes (rare). The causes of congenital lobar emphysema are multifactorial.
D. Atelectasis with compensatory hyperinflation. Compensatory hyperinflation may appear as a pneumothorax on a chest radiograph.
E. Pneumopericardium. In neonates, pneumopericardium and tension pneumothorax can both present as sudden and rapid clinical deterioration. In pneumopericardium, the blood pressure drops, heart sounds are distant or absent, and pulses are muffled or absent. Massive abdominal distention can also be seen. In tension pneumothorax, the blood pressure may initially increase, but then hypotension follows. The chest radiograph easily differentiates the two. A pneumopericardium has a halo of air around the heart (see Figure 11–18). The more common event is a tension pneumothorax. If one is unsure and time does not permit radiographic verification, quick transillumination can be done. If not available or unsure of results, it is better to insert a needle in the chest on the suspected side. If no response, then a needle should be inserted on the other side. If there is still no response, then the diagnosis of pneumopericardium should be considered.
F. Congenital diaphragmatic hernia (CDH). A developmental defect in the diaphragm allows the abdominal viscera to protrude into the chest, which causes pulmonary hypoplasia and decreased pulmonary vasculature and dysfunction of the surfactant system. Ninety percent are on the left side. CDH is often mistaken as a left tension pneumothorax. Presents with respiratory distress, cyanosis, and circulatory insufficiency. It can be hard to differentiate a left-sided pneumothorax from a typically left-sided CDH. With CDH, the abdomen is scaphoid, and the spleen cannot be palpated. There can be a mediastinal shift on radiograph. If chest tubes are placed, there is a risk of perforating the herniated viscus.
G. Congenital cystic adenomatoid malformation (CCAM). This rare congenital abnormality of the lung results from abnormal embryogenesis and reduced alveolar growth. The infants present with respiratory distress. Tachypnea and cyanosis can be presenting signs that are similar to a pneumothorax. Many of these are detected on ultrasound prenatally. A chest radiograph usually identifies the mass containing air-filled cysts. (See Chapter 135.)
H. Congenital pulmonary cysts. These are space occupying, involve one or more lobes, have atelectasis of the adjacent lobe, and have symptoms similar to pneumothorax.
IV. Clinical findings
A. Physical examination. Specific findings are discussed in Section II.A. Transillumination is a useful rapid bedside technique in neonates (see Section IV.C and Chapter 40).
B. Laboratory studies. Blood gas levels may show decreased Pao2 and increased Pco2, with resultant respiratory acidosis.
C. Imaging and other studies
1. Transillumination of the chest is a rapid bedside method to identify a pneumothorax. Always verify the diagnosis of pneumothorax by a chest radiograph if time permits. The room lights are lowered, and a fiber optic transilluminator is placed along the posterior axillary line on the side on which pneumothorax is suspected. If a pneumothorax is present, the chest “lights up” on that side. The transilluminator may be moved up and down along the posterior axillary line and may also be placed above the nipple. Transilluminate both sides of the chest and then compare the results. If severe subcutaneous edema is present, transillumination may be falsely positive. Premature infants with pulmonary interstitial emphysema may also have a false-positive transillumination. Large infants with thick chest walls do not transilluminate well.
2. Chest radiographs are the method of choice for diagnosing pneumothorax. Early pneumothoraces are difficult to diagnose. Early on, there is separation of lung from the chest wall with no lung markings in that space. In infants there is a tendency of pleural air to cloak diaphragmatic and mediastinal surfaces. A pleural line is often not seen, but a well-defined costophrenic sulcus (deep sulcus sign) can be observed. The following films will aid the diagnosis:
a. Anteroposterior (AP) view of the chest (see Figure 11–20) will show the following:
i. A shift of the mediastinum away from the side of pneumothorax (with tension pneumothorax).
ii. Depression of the diaphragm on the side of the pneumothorax (with tension pneumothorax).
iii. Displacement of the lung on the affected side away from the chest wall by a radiolucent band of air.
b. Cross-table lateral view will show a rim of air around the lung (“pancaking”).It will not help to identify the affected side. You must have an AP film to identify the side of the pneumothorax. This film must be considered together with the AP view to identify the involved side. Pleural air tends to collect anteriorly and may require the CT or lateral decubitus view.
c. Lateral decubitus view (shot through the AP position) will detect even a small pneumothorax not seen on a routine chest radiograph. The infant should be positioned so the side of the suspected pneumothorax is up (eg, if pneumothorax is suspected on the left side, the film is taken with the left side up).
3. Ultrasound examination of the lungs. The absence of lung sliding (grainy appearance) and comet tails (normal pleura reflecting sound waves) confirms the ultrasound diagnosis of a pneumothorax. The sensitivity and specificity of ultrasound is 100% and 93% for a complete pneumothorax, and 79% and 100% for a radio-occult pneumothorax. As a bedside tool, this is useful to diagnose a pneumothorax.
4. Transcutaneous carbon dioxide (tcpCO2) reference percentiles with changes over time can indicate a pneumothorax or a blocked or misplaced endotracheal tube.
5. Echocardiography and renal ultrasound may be indicated in spontaneous pneumothorax in term infants, as some of these infants can have renal and cardiac anomalies.
A. Symptomatic pneumothorax
1. Tension pneumothorax. Symptomatic (tension) pneumothorax is an emergency! A 1- to 2-minute delay could be fatal. If a tension pneumothorax is suspected, act immediately. It is better to treat in this setting, even if it turns out that there is no pneumothorax. There is no time for x-ray confirmation. If the patient’s status is deteriorating rapidly, a needle or catheter over needle can be placed for aspiration, followed by formal chest tube placement. There is no specific sign that distinguishes a tension from a nontension pneumothorax. Signs of a tension pneumothorax from above can also occur in a nontension pneumothorax, except the signs and symptoms are more severe in a tension pneumothorax.
a. Needle aspiration (see Figure 70–1) can be done as an emergency. Often times this is all that is necessary if the infant is not on a ventilator. If on a ventilator, a chest tube placement may need to be followed by needle aspiration.
See Emergency Pneumothorax Needle Image Below
i. The site of puncture should be at the second intercostal space along the midclavicular line on the suspected side of pneumothorax. Cleanse this area with antibacterial solution. The fourth intercostal space at the anterior axillary line can also be used (needle would be inserted above the fifth rib).
ii. Connect a 23- or 25-gauge butterfly needle or a 22- or 24-gauge catheter over needle (Angiocath) to a 10–20-mL syringe with a stopcock attached.
iii. Palpate the third rib at the midclavicular line. Insert the needle (perpendicular to the chest surface) over the top of the third rib at the second intercostal space, and advance it until air is withdrawn from the syringe. Have an assistant hold the syringe to withdraw the air. The needle may be removed before the chest tube is placed if the infant is relatively stable, or it may be left in place for continuous aspiration while the chest tube is being placed. If an Angiocath is used, the needle can be removed and the catheter left in place.
b. Chest tube placement is discussed in Chapter 27. This is necessary in most infants on mechanical ventilation with a tension pneumothorax.
c. If the infant does not improve with a chest tube. Suspect extrapleural air leaks such as a pneumoretroperitoneum, which has been reported in infants with pneumothorax. If air is still present on the radiograph, consider these causes: obstruction of the tube with blood or pleural fluid, disconnected drainage tube, ineffective water seal, new air leak, or a lung perforation.
2. Nontension pneumothorax. Depending on the infant, oxygen supplementation, needle aspiration, chest tube placement, or conservative management (oxygen, close observation) is done.
a. Mild symptoms. Some require observation only.
b. Symptomatic spontaneous pneumothorax (not on ventilator). Needle aspiration and possible chest tube placement. In one study the majority of infants did not require a needle aspiration or chest tube and could be managed with supplemental oxygen or close observation.
c. Symptomatic spontaneous pneumothorax (on the ventilator). Needle aspiration and chest tube placement. Some infants on a ventilator who have a pneumothorax could be treated conservatively without a chest tube, but they usually are more mature, on lower ventilator settings, and had better gases at the time of the pneumothorax as compared with the infants who required a chest tube.
B. Asymptomatic pneumothorax
1. If positive-pressure mechanical ventilation is being used:
a. Needle aspiration/chest tube. A chest tube will probably need to be inserted because the ventilator pressure will prevent resolution of the pneumothorax, and tension pneumothorax may develop. Sometimes needle aspiration is allthat is needed. If a pneumothorax develops in a patient who is ready to be extubated, clinical judgment must be used in deciding whether a chest tube should be placed.
b. Expectant management. Recent studies are showing that some select infants on a ventilator can be managed without a chest tube.
2. If positive-pressure mechanical ventilation is not being administered and there is no underlying lung pathology,these may be considered.
a. Close observation with follow-up chest radiographs every 8–12 hours or sooner if the infant becomes symptomatic. The pneumothorax will likely resolve within 24–48 hours.
b. Nitrogen washout therapy (controversial). Allows a more rapid resolution of the asymptomatic pneumothorax but is infrequently used due to the toxicity of 100% oxygen. The infant receives 100% oxygen for 8–12 hours; less nitrogen is able to enter the lungs, and at the same time absorption of nitrogen from the extrapleural space is increased and then exhaled. The total gas tension is decreased, which also facilitates absorption of nitrogen by the blood. The method should be used only in full-term infants in whom retinopathy of prematurity will not be a problem. Some NICUS give only enough oxygen to maintain a pulse oximetry reading >90% and have found resolution to be similar to the hyperoxic group.
C. Persistent pneumothorax. Generally defined as a pneumothorax that persists >7 days in the absence of mechanical problems. Sometimes infants who have chest tubes still have air leaks that persist for more than a week. These infants have episodes of instability when air reaccumulates; some require a new or replacement chest tube and an increase in their ventilator settings. These are treated to decrease the complications associated with air leaks (air embolus, hypotension, intracranial hemorrhage). The following have been used:
1. High-frequency oscillatory ventilation (HFOV) or high-frequency jet ventilation (HFJV) can be used due to lower mean airway pressures.
2. Unilateral lung intubation has been reported as an efficient and relatively safe therapy for pneumothorax. Duration of therapy should be a minimum of 48 hours.
3. Fibrin glue, such as CryoSeal C (ThermoGenesis Corp., Rancho Cordova, CA), has been injected in the chest tube with a marked reduction in the air leak. Risks include hypercalcemia, localized tissue necrosis, bradycardia, diaphragmatic paralysis, and pneumothorax on the contralateral side. More studies are needed before this treatment can be routinely recommended.
D. Pneumomediastinum. May progress to a pneumothorax or pneumopericardium. Close observation is required.
E. Congenital lobar emphysema. If asymptomatic, conservative management with observation. If symptomatic or respiratory failure is occurring, the treatment is usually surgical excision of the affected lobe.
F. Atelectasis with compensatory hyperinflation
1. Chest physiotherapy and postural drainage should be initiated. Chest physiotherapy should be used with caution in premature infants. A study showed an association with intraventricular hemorrhage and porencephaly in extreme premature infants.
2. Treatment with bronchodilators is indicated.
3. Positioning the infant with the affected (hyperinflated) side down may speed resolution.
4. Bronchoscopy. May be necessary with mucous plug.
G. Pneumopericardium. This should be treated emergently by pericardiocentesis (see Chapter 38).
H. Cystic adenomatoid malformation or congenital cyst. Surgery is the treatment of choice.
FIGURE 70–1. Site of emergency needle aspiration for tension pneumothorax is puncture at the second intercostal space (ICS) along the midclavicular line.
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