Nontraumatic tension pneumopericardium in nonventilated pediatric patients: a review.

BACKGROUND AND AIMS: Pneumopericardium is a rare air leak syndrome caused by the abnormal presence of air in the pericardial sac, with a high risk of morbidity and mortality. It is clinically divided into nontension and tension pneumopericardium, with the latter resulting in a decreased cardiac output and circulatory failure. There are limited data regarding nontraumatic pneumopericardium in nonventilated pediatric patients. Therefore, we aimed to describe a case of tension pneumopericardium and review the available literature. METHODS: Case report and literature review of nontraumatic pneumopericardium in nonventilated pediatric patients. RESULTS: A 2-month-old infant developed cardiac tamponade secondary to tension pneumopericardium 11 days after cardiac surgery promptly resolved with pericardium drainage. We reviewed the literature on this topic and retrieved 50 cases, of which 72% were nontension whereas a minority were tension pneumopericardium (28%). Patients with tension pneumopericardium were mostly neonates (35.7% vs 22.2%), presented with an isolated air leak (64.3% vs 36.1%), and had a history of surgery (28.6% vs 8.3%) or hematological disease (28.6% vs 11.1%). In all nontension cases, treatment was conservative, whilst in all other cases, pericardiocentesis/pericardium drainage was carried out. There was a high survival rate (86.0%), which was lower in patients with tension pneumopericardium (71.4% vs 91.6%). CONCLUSIONS: Pneumopericardium is a rare condition with a higher mortality rate in patients with tension pneumopericardium, which requires immediate diagnosis and treatment. In nonventilated patients, tension pneumopericardium occurred more frequently in neonates, as an isolated air leak, and in those with a history of surgery or hematological disease.

Pneumopericardium in very low birth weight infants.

The objective of this study was to describe the incidence, neonatal correlates, and outcome of pneumopericardium (PPC) in very low birth weight (VLBW) < or = 1.5 kg infants. Forty-seven VLBW infants with a PPC, born during 1977 to 1989, were compared with a cohort of 1302 ventilated VLBW infants. PPC developed in 2% of 2389 VLBW infants and 3.5% of 1349 ventilated infants. The mean birth weight (1008 +/- 220 gm), and mean gestation (27 +/- 2 weeks) of the PPC cohort was similar to the control cohort. Thirty-two (68%) of the infants with PPC were male, compared with 691 (53%) of the ventilated infants (p < 0.05). Eight (17%) of the infants with PPC survived, compared with 780 (60%) of the control cohort (p < 0.00001). The oxygenation index significantly increased before PPC, and was significantly higher in nonsurvivors than survivors. Four (50%) of the PPC survivors had neurodevelopmental impairment at 20 months, compared with 35% of the control cohort. Pneumopericardium is a rare event with high morbidity and mortality. Clinicians should suspect this diagnosis in VLBW infants with a rising oxygenation index and subsequent acute deterioration.

Pneumopericardium resulting in cardiac tamponade.

Cardiac tamponade most commonly results from accumulation of blood or other fluids within the pericardial sac. However, there is a growing body of clinical evidence showing that pneumopericardium can lead to cardiac tamponade in a large number of patients. Including those in the present report, a total of 252 patients with pneumopericardium are available for review. Interestingly, cardiac tamponade developed in 94 patients, or 37% of this group, because of air within the pericardial space. Pneumopericardium resulting in tamponade most frequently occurs in trauma patients or in newborn infants requiring positive pressure ventilation. This syndrome can be recognized promptly because of its characteristic physical findings and radiographic features. Although air tamponade can be treated effectively by either needle aspiration or insertion of a pericardial tube, the development of a pneumopericardium is a bad prognostic sign. Out of the 221 patients reported in the literature whose outcome is known, 127 (57%) died. In the group with a tension pneumopericardium, the mortality was 56% (53 out of 94 patients). Even without the development of tension, however, pneumopericardium was associated with a 58% mortality (74 out of 127 patients) due to other underlying disease processes.

Neonatal pneumopericardium: analysis of ventilatory variables.

Case reports of all infants admitted to the NICU from 1971 to 1982, who developed a pneumopericardium (PPC) while receiving intermittent positive-pressure ventilation, were reviewed in order to determine those variables of assisted ventilation associated with the occurrence of PPC. Of 19 infants seen during the 11-yr period, 16 had respiratory distress syndrome (RDS) and 3 had other forms of severe pulmonary disease. Mean birth weight was 1720 g, gestational age 32 wk, and age at occurrence 59 h. Peak inspiratory pressure (PIP) (mean 32 cm H2O), inspiratory time (IT) (0.74 sec), and mean airway pressure (MAP) (mean 17 cm H2O) were significantly elevated just before occurrence of the PPC, compared with values 6 h previously. PEEP (mean 3.8 cm H2O), ventilator rate (mean 40/min), PaCO2 (mean 41 torr), P(A-a)O2 (mean 443 torr), and inspired oxygen concentration (FIO2, 0.77) were unchanged. MAP was significantly lower (mean 11 cm H2O) 6 h after the event compared with just before (mean 14 cm H2O) in infants who died, suggesting that lowering airway pressure does not improve survival. These data indicate that high PIP, prolonged IT and elevated MAP are associated with the development of PPC. MAP provides a composite of pressure transmitted to the airways and may be the more useful index in preventing barotrauma and pulmonary air leak.

Neonatal pneumopericardium: a surgical emergency.

Pneumopericardium, a complication of ventilatory management of neonatal respiratory distress syndrome, may result in cardiac tamponade. Pneumopericardium occurred in 47 premature infants (mean birth weight, 1,894 gm) at the University of Minnesota Hospital between July, 1972, and January, 1981. At the onset of pneumopericardium, 44 of 46 intubated patients were on positive end-expiratory pressure (PEEP) and 1 patient was ventilated using a mask. Five infants were asymptomatic, while 42 were seen with sudden hypotension, bradycardia, and hypoxia an average of 57 hours (range, 1 to 312 hours) after the commencement of ventilatory support. Pneumothorax (38 instances), pneumomediastinum (21), pulmonary interstitial emphysema (29), pneumoperitoneum (6), or a combination of these conditions was noted prior to or simultaneously with pneumopericardium in 46 infants. Pneumopericardium was not treated in 14 patients, 10 of whom were symptomatic and 4 asymptomatic; there were 5 deaths in this group. The group of 33 infants treated for this complication underwent either pericardial aspiration (2 patients), aspiration followed by pericardial tube placement (12 patients), or pericardial tube placement alone (19 patients). All 33 patients who underwent treatment had resolution of symptoms, but pneumopericardium recurred in 13 with 5 deaths. Causes of recurrence were tube or aspiration failure in 10 infants and tube removal prior to cessation of PEEP in the other 3. There were five complications related to tube placement, resulting in 2 deaths due to myocardial laceration following percutaneous insertion. Of 35 neonates surviving pneumopericardium, 12 were discharged from the hospital and 23 died of complications of respiratory distress syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

Pneumopericardium in neonates: is it PEEP or is it PIP?

Thirteen premature infants receiving mechanical ventilation for respiratory distress syndrome developed pneumopericardium. All had high peak inflation pressures (mean, 42 mm Hg; range, 26 to 60 mm Hg), and all were on positive end-expiratory pressure (PEEP) ventilation (mean, 3.1 mm Hg; range, 2.1 to 5.7 mm Hg) at the time that pneumopericardium occurred. Arterial blood gases, indices of respiratory support, and hemodynamic data were reviewed before and after the onset of pneumopericardium in all patients. There was a statistically significant increase in peak inflation pressure (PIP) over the 16 hours prior to onset of pneumopericardium (p less than 0.05). There was, however, no significant relationship between onset of pneumopericardium and other respiratory variables, including PEEP. In the majority of patients, pneumopericardium was associated with cardiac air tamponade. Various forms of treatment for pneumopericardium were attempted, including observation, needle aspiration, and insertion of pericardial tubes. Review of the therapy indicates that insertion of a pericardial tube under direct vision is the safest and most effective means of treating pneumopericardium in infants. These data also suggest that PIP is more important than PEEP in predisposing neonates with respiratory distress syndrome to pneumopericardium.

[Pneumopericardium in the newborn. Study of 5 cases and a review of the literature]. / Neumopericardio en el recién necido. Estudio de 5 casos y revisión de la literatura.

Experience with 572 events of mechanical ventilation that developed 5 cases of pneumopericardium thru the period from August 1975 to August 1979 is reported. From this series, at least two cases were in direct relationship with the administration of high mean ventilatory pressure; other two could be related to inadvertently PEEP; finally the remaining case is questioned to be a pericardium congenital defect since no relation with the other causes of pneumopericardium could be explained. Surviving from the pneumopericardium and from the drainage, pneumopericardium is commented according to what has being reported in the literature that follows about the same trend of our series where the relative fatality risk is higher when a pericardiumcentesis is practiced.

Neonatal pneumopericardium.

Six cases of pneumopericardium in neonates with hyaline membrane disease were observed during a six-month period. Five babies were receiving positive inspiratory or expiratory pressure or both. All but one had other extra-alveolar air collections. In three cases, sudden decrease in PaO2 was the only recorded sign that led to diagnosis. Pericardial aspiration was performed in four babies; one died and three either survived or died later of unrelated disease. One neonate was not treated and died of other causes. Treatment was delayed in the sixth infant; the pneumopericardium disappeared spontaneously but soon reappeared and contributed to a fatal outcome, although a drainage catheter was inserted. This experience and review of other authors' observations suggest that prompt drainage by catheter and continuous suction is indicated.