A 27-week four days old preterm male infant was born from a dichorionic diamniotic twin pregnancy with low birth weight(1135 gr). His prenatal examinations were completed regularly without reported complications. In the 27th week of pregnancy, the mother experienced premature membrane rupture, contractions, and bleeding. She was treated with antenatal steroid treatment, and cesarean delivery was planned due to an arrested birth. During birth, the neonate was hypotonic, and he had no respiratory effort, requiring intubation one minute after birth due to respiratory failure. An uncuffed endotracheal tube was used. His APGAR scores were 4,6 and 7 in the 1st, 5th, and 10th seconds respectively. He was transferred to the newborn intensive care unit(NICU) for further management. After a diagnosis of respiratory distress syndrome was made, treatment with endotracheal poractant alfa 200 mg/kg, parenteral ampicillin-gentamicin, and caffeine citrate was initiated. His ventilation settings were arranged to assist control and volume guaranteed mode with maximum inspiring pressure of 20 cm/H²O. His cranial USG showed no abnormalities.
On hospital day 3, his respiratory status stabilized, and he was extubated to nasal intermittent positive pressure ventilation. Unfortunately, he could not tolerate extubation and needed to be reintubated. His antibiotics were escalated to vancomycin-meropenem due to clinical deterioration.
During hospital day 5, the baby had worsening acute hypoxic respiratory failure. A chest x-ray revealed mediastinal pneumothorax(Fig. 1A), with a follow-up x-ray one hour later showing accelerated pneumothorax on the left side (Fig. 1B) and mediastinal shift to the right. To treat the pneumothorax, a thorax tube was placed through the left 5th intercostal space. Repeat x-rays showed an expanded lung on the left side and air bronchograms on the right(Fig. 1C). Ten hours later, he had persistent acidosis and hypoxia; therefore, another x-ray was obtained, displaying a repeat pneumothorax on the left side(Fig. 1D). The thorax tube was set to continuous suction, resulting in a reduction of pneumothorax on subsequent imaging.
On the 6th day of hospitalization, an echocardiogram revealed a 3 mm patent ductus arteriosus(PDA) with mostly left to right two-way shunts and pulmonary hypertension. His oxygen saturation levels were approximately 80%, and his arm-leg saturation differences were higher than 15 mm, suggesting differential cyanosis. These findings were suggestive of persistent fetal circulation; therefore, pediatric cardiology advised against the closure of PDA. A new chest x-ray showed a collapsed left lung(Fig. 1E), and a second chest tube was placed in the left hemithorax.
The decision to perform a surgical intervention was made upon no resolution of the pneumothorax after the second chest tube and the patient’s clinical deterioration. A left posterolateral thoracotomy was performed. During the exploration, a 1 cm perforated area between the left bronchus and carina was found by following the air leak through the visceral pleura. The perforated area was repaired by using a pleural patch, and suturing with 6.0 prolene was performed. At the end of the procedure, there was no visible bleeding or air leak. The anesthesiologist applied high-pressure air via the endotracheal tube to check for any air leaks. A chest tube was inserted, and the thoracotomy incision was closed by layers. Chest x-ray showed an expanded left lung. (Fig. 1F) After the procedure, the baby was transferred to the NICU again.
Three days later, the baby experienced another episode of hypoxia which was found to be secondary to a repeat left-sided pneumothorax. Consequently, a second thoracotomy was performed using the same technique as the prior surgery, with an air leak emanating from the same area. The perforated area was repaired using a pleural patch and the left 5th intercostal muscle long peduncle (Fig. 2A). Fibrin glue and spongestan were used as anchorage on top of the patch (Fig. 2B). After the repair, no leak was found with the use of maximal airway pressure. A PDA ligation operation was also performed simultaneously during the procedure (Fig. 2C). There was no air leakage in the repeated x-ray. The baby was transferred to the NICU again. Both the first and second thorax tubes were removed on postoperative days 0 and 5, respectively. There were no signs of air buildup or pneumothorax on the following days. On the 161st day of admission, the patient was discharged home with a home-type ventilator and 30% oxygen support.