Ultrasonography and X-Ray guided drain placement to evacuate a pneumopericardium/pneumomediastinum in a 1-day-old infant

Abstract

Ultrasonographic (US) guided procedures have wide range of application in the abdomen and pelvis, however their role is somewhat limited in the chest due to complete reflection of the ultrasound beam by the air in the lungs, preventing the direct imaging of the tissues deep to the air-sound interface. Most of the chest procedures, other than the exception of thoracentesis, rely on the use of CT (computed tomography) scan. The disadvantages of using CT scan is the cost, lack of portability, and most importantly the radiation involved, particularly in case of infants and children, whose tissues are more radiosensitive than the adults. Identification of air by Ultrasonography can help direct needles and wires, to accomplish procedures which may otherwise need CT. A 1-day-old infant with respiratory distress syndrome (RDS) on a ventilator, developed an expanding symptomatic pneumopericardium/pneumomediastinum. The patient was too unstable to leave the neonatal intensive care unit (NICU), so a pericardial/mediastinal drain was placed under ultrasonographic and radiographic guidance. This case, highlights a method for bedside treatment of pneumopericardium/pneumomediastinum in an unstable neonate. This procedure may be equally effective in older children and adults.

Keywords: Cardiac tamponade; pneumomediastinum; pneumopericardium; respiratory distress syndrome; ultrasound guided drain of pneumopericardium.

Figure 1

Anteroposterior radiograph of the chest showing granular opacities in both lungs consistent with Respiratory distress syndrome

Figure 2 (A and B)

(A) Anteroposterior radiograph of the chest, 2 hours after birth shows development of pneumopericardium/pneumomediastinum (black arrows). (B) Anteroposterior radiograph one hour following the radiograph in Figure 2A, shows enlargement of the pneumopericardium/pneumomediastinum

Figure 3 (A and B)

(A) Suprasternal notch imaging plane. Echobright imaging artifact consistent with air in the superior mediastinum (arrows). INN; innominate vein, I; first branch of aortic arch, II; second branch of aortic arch and III; third branch of aortic arch. (B) Subcostal imaging plane demonstrating echobright artifact consistent with air along the left ventricular free wall (arrows). RV; right ventricle, IVS; interventricular septum, LV; left ventricle

Figure 4

Sagittal ultrasound of the chest in the region of the right lower chest, showing dirty shadowing consistent with air echoes (white arrows)

Figure 5 (A and B)

Anteroposterior (A) and lateral (B) radiographs of the chest, after advancing a Bentson wire (black arrows), shows the wire in good position coursing through the pericardial/mediastinal space

Figure 6

Anteroposterior radiograph with pericardial drain placement shows near complete evacuation of the pneumopericardium/pneumomediastinum. The drain is located in the right side of the heart/mediastinum (black arrow)