Pulmonary

Interstitial

Emphysema

and

Precursors
A Clinical
A. KIRSCHNER,

PAUL

in

and

Pathologic

Infant

Study

AND

York,

Newborn

Sequelae*

M.D.,

New

the

New

Lol-FE

STRAUSS,

M.D.t

York

INTRODUCTION

ULMONARY

has
precursor

INTERSTITIAL

been
of

astinal
emphysema,
pneumoperitoneum)
tions.

panies
infant.
the

substantial

these
While

mortality

have

and

animalsL?sO

newborn

vivors

accom-

anatomY

applied

is to present
of

the

pulmonary

physema
in the newborn
infant
relate
the pathologic
with
the

precursors

hundred

ninety-seven
live-born

days
of birth
during
the
inclusive
were
reviewed.

period
Forty-

seven

these

of pulmonary
or without

survivor
seven
thorax.

of

cases

the

#{149}*Associate

gery,
tAssociate

Division
Hospital,

lived

four

days.

of

Surgery

Pediatric

and

Attending

Sinai
Attending

of
N.

Pediatric
Y.

Surgeon

Hospital,

for

N.

Pathologist

cut

will

Pathology,

4).

monary
occasion

for

lungs

are

3).

They

tend

col-

by
of
At

the
the
times

dissection

of

2) or down
blebs
on the
recognized
to

septa

of

the

with

be

like

Sinai

normal

uncut

grouped
strings

lungs

spaces
of air.

with

in

the

have

never

point

of

have

of

hand

lens

by
will

interof the
reveal

bronchovascular
may

be

observed
alveolar
the

for

1 indicates
collections

is necessary

produced
Examination

noted

responsible

Table

of

417

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look

compression

We

bleb
Mount

air

1).

neck
(Fig.
Subpleural

the

clefts

Vascular

Sur-

charge

or

or mediastin-

should

surface

these

Y.
in

chest

the
thymus
gland.
A
will be noted
surroundlungs
in the hilar areas.

interlobular

Fixation

The

Thoracic

is
bulg-

abnormal

(Fig.

the

to preserve
the
stitial
collections

Pathol-

Pathology),

information
inspection,
of the

is easily
diagnosed
the
areolar
tissue

in

(Fig.

along

Hospital.

Mount

clinical

pneumo-

beads.

Only

and

of

ease

pneumoinfants
with

survival

so as

or

indicating

prosector

surface

evi-

emphysema
The
longest

detectable
four

with

of

Sinai

showed

interstitial
sequelae.

Departments

(Division

Mount

cent)

surreport.

conducted

Pneumomediastinum

air up into
retroperitoneally.

survived.
Thirteen
of the 47
had severe
congenital
an-

incompatible

*From
ogy

its

clinically
additional

pneumothorax
necropsied
omalies

per

these

had
An

infants

be

mediastinum

The

in seven
1952-1960

(9.5

bubbles

anterior

necropsics
with-

of

should

they
may
elevate
collar
of air vesicles
ing the roots of the
dying

dence
with

on

of this

pneumothorax

al emphysema
blebs
of air

em-

and to corclinical
find-

MATERIAL

Four

body
FINDINGS

Prior

lections.

ings.

performed

post-

clinical

low-lying
abdominal
viscera
(if the abdomen
is opened
first)
are highly
suggestive.
The
body
cavities
should
be opened
under

the

interstitial

34

four

Upon
preliminary
one
or both
sides

water,

purpose
sequelae

main

necropsy

to overlook

helpful.
ing of

are

to

the

peritoneum.

has been
in adults

then

to form

The
not

described,

understanding
observations

leaving
and

NECROPSY

lung.4

Our
and

amply

and

separately

examinations

and
of situa-

rate

morbid

of our
from

considered

mortem

in the newborn
manifestations
in

been

of underlying

few.58 Most
extrapolated

to be the
(medi-

pneumothorax
a variety

complications
the clinical

neonate

reports

in

be

EMPHYSEMA

shown
by Macklin
pneumomediastinum

of

rays.
seen

the
rupture,
torn

but

pneumothorax.

the

distribution
Lack

on

subpleural

the
air.

(Fig.

intrapul-

of abof absolute

KIRSCHNER

418

TABLE

I.Pulmonary

1-DISTRIBUTION

interstitial

emphysema:

Bilateral

17

Unilateral

10

Focal

Location
2.

not

stated

a.

with

(L

34

COLLECTIONS

or

mediastinal

without

pneumomediastinum

Bilateral

pneumothorax:

Bilateral
or

mediastinal

pneumothorax:

b.

with

or

mediastinal

pneumothorax:

without

emphysema:
emphysema:

between

mediastinal

emphysema

indicates

that

directly

into

pleural

of

subpleural
space

piratory

or

emphysema:
11

pulmonary
emphysema:

Unilateral

pulmonary

interstitial

emphysema:

Bilateral
pneumothorax:

Bilateral
pneumothorax:

blebs

Cases

cant
the

Severe
anterior
pneumomediastinum
emphysema
and
bilateral
pneumotho-

cause

of pneumothorax

classic

tinum

circuitous

had

in addition

route

as emphasized

case

via

the

by Macklin.

unilateral

Only

pulmonary

Four

of

and
the

11

one

interstitial

pneumomediastinum
emphysema

to

medias-

or mcdibilateral
cases

pneumoof

pneumo-

or

of thymus
by emphysematous
of right
ventricle.
Pulmonary
of
both
lower
lobes
not
(Premature
infant,
case
R.S.;
weight
no resuscitation;
delayed
onset
of resdistress;
survived
42 hours.)

Downloaded From: http://journal.publications.chestnet.org/ on 12/05/2014

Unilateral
interstitial

Unilateral

is a signifi-

elevation
dilatation
emphysema

pulmonary

thorax.

rax.
Note
blebs,
and
interstitial
well
seen,
2250
gm.;

emphysema:

Bilateral

astinal

1:

pulmonary

interstitial

emphysema,

FIGURE
mediastinal

Unilateral
2

pulmonary
emphysema:

pneumomediastinum
and pneumothorax

rupture
the

emphysema:

Bilateral
interstitial

pneumothorax:

correlation

pulmonary

interstitial

4 cases

Unilateral
pneumothorax:

Unilateral

pulmonary

emphysema:

pneumothorax:

pulmonary

emphysema:

interstitial
Pneumomediastinum
a.

CASES

7 cases

emphysema:

Bilateral

interstitial

3.

34

only)

pneumothorax:

Unilateral

AIR:

R 3)

interstitial

b.

OF

Cases

pneumothorax:

Unilateral

Diseases
the Chest of

Cases

(microscopic

pneuiiomediastinum

Bilateral

ABNORMAL

STRAUSS

II

Pneumothorax:

OF

AND

FIGURE

tures
astinal
gm.;

2:
extending

Interstitial
from

emphysema.
with
intrauterine

suscitation;

survived

emphysema
pneumomediastinum
(Full-term
fetal

infant,
distress;

one

one-half

and

of

neck
or
weight
required

hours.)

strucmedi3459
re-

Volume

46, No.
1964

October

3:
blebs
fetal

FIGURE

A few
uterine

Thoracic
are seen
distress;

thorax
did
or mediastinal
Table
of

not

important

of

EMPHYSEMA

a male

case
This

predominance

Twenty-six

2000
that

of

the

factor.

in-

Fetal

dis-

tress
during
of resuscitative

delivery
and
the employment
measures
occurred
in slight-

ly more
The

half of the entire

group.
significant
pulmonary
findings

are

than
most

summarized

in

Table

3.

All

NEWBORN

but

showed
exception

and

34

grams
or more
at birth.
prematurity
is not
an

predisposing

IN

one

In

vigorous

a general

volvement
ated

rhage

lung

edema

that

in the
had

It

trachea

Sex:

only
of

Male

or

in

larger
prior

mucus,

vernix
CLINICAL

death

resuscita-

when
complete

the
tree,

bronchi
to

during

remained

in

was

too

removal.

it

It

caseosa

and

INFORMATION

CASES

21
13
Male

Female

Total

gm.

3000-3499

gm.

2500-2999

gin.

2000-2499

gm.

Over

Downloaded From: http://journal.publications.chestnet.org/ on 12/05/2014

and

permit

2-GENERAL

Female

hours.)

This
hemor-

found
bronchial

removed

34

one-half

aerwith

alone

was
the

of

suction
to

TABLE

resuscita-

of

alternating

occurring

been

endotracheal

consisted

required

in-

zones

parenchyma.
pneumonia,

Aspirated
material
deeper
ramifications

inspissated

distress;

pathology.
hemorrhage

combinations.

tion.

interstitial
emphysema;
air compressing
and
deartery.
(Hematoxylininfant,
weight
3459
gin.,

blebs.
intra-

pulmonary

with

unexpanded
to aspiration,

and

various

by

of

of way,

patchy,

or overexpanded

areas
of
was due

subpleural
gin.,
with

resuscitation.

sort

was

usually

4:
Pulmonary
perivascular
collections
forming
a medium-sized
eosin,
x45)
(Full-term
with
intrauterine
fetal
tion;
survived
one and

and
3040

substantial
lung
had
subdural

required

since

FIGURE

419

bilateral
pulmonary
interstitial
emphysema
the thymus.
(Full-term
infant,
weight
survived
less than
one hour.)

have
pneumomediastinum
emphysema.

2: 1.

weighed
suggests

INTERSTITIAL

situs
showing
severe
also on the surface
required
resuscitation;

2 indicates

almost

fants
This

PULMONARY

3500

Under
Fetal

2000

gm.

Distress

Resuscitative

Measures

6
18 cases

(5 unstated)

19 cases

(3 unstated)

KIRSCHNER

420

TABLE

3-NECROPSY

FINDINGS-34

AND

terminal

CASES

was
Pulmonary

Pathology-33

cases

Aspiration

16
16

(2 focal)

Atelectasis

28

(1 focal)

11

(3 without

14

(Focal)

membranes

Hemorrhage
Cardiac

Dilatation-17

other

pathology)

Nervous

System

14
4

Cerebral

sometimes
of focal
tial

was

Distribution

of a patchy

obstructive

bronchial

nature

emphysema
obstruction

deep
with
due

and

was

areas.
When
occurred
with

the

with

the

patchy
pattern

alveolar

lung

was

aeration.

In

interstitial

a few

over-expansion

of

Downloaded From: http://journal.publications.chestnet.org/ on 12/05/2014

whether

with

and

the

that
usually
hyaline

when

hemorrhage

alone

alteration

in pul-

some
other
is operative.

poorly
On the

an
or

asso-

emphyfashion.
It

heart

disease
which
blood
flow
was

absent.

common

due

to compression

with

the

interstitial

Central
found
in

to the
em-

others

interstitial
patchy

congenital
pulmonary

monary

5:
Uneven
aeration
of lung.
Patchy
obstructive
emphysema
(left),
adjacent
to non-aerated
lung
with
aspirated
amniotic
sac
contents
in
bronchi
and alveoli.
(Hematoxylin
and
eosin,
x45)
(Full-term
infant,
weight
3700
gm.;
Cesarean
section;
meconium-stained
amniotic
fluid;
required
resuscitation;
survived
nine
hours.)
FIGURE

predispose
interstitial

premature.

circulation
mechanism

infilmin-

the

membrane

hemorrhage,

occurrence

tation,
particularly
(17 cases)
suggests

Hence

hyaline

newborn

or whether

hand
affects

ap-

hyaline
definite

or

agreement

more

be stated

The

appar-

in

larger
the

conspicuously

inflammation,

is

had

aspiration.
the

with
pulmonary
also occurs
in

other
often

Again
em-

lungs

the

membrane

alveoli

cheese

of ourselves
and
interstitial
emphysema

monary
understood

exudate

mechanism.
of obstructive

non-aerated

of

This

is a factor

obstructed

lungs
were
more
diffusely
exudate
and showed
only

predominantly

physema.

cannot

(Fig.
of the

infants
pneumonia

se does not
of pulmonary

Intrapulmonary

predominated,
it also
type of distribution

obstructing
pattern

and

ent.
Some
trated
with

bizarre

to

inflammatory

physema

imal

confined

pneumonia
in a scattered

acting
as the
the alternating

per

ciated
sema

to par-

alternating

11

that

syndrome
development

areas

complete
obstruction
and
atelectasis
5). Pneumonia
occurred
in over half
cases

in

of
without

of intra-uterine

affects

meconium.

lung

atelectatic

a Swiss

6).

feeling

observations
pulmonary

Subarachnoid

the

7 observed

Hemorrhage-i

Subdural

three

it is our

15 not stated
Central

(Fig.

evidence

present

and

producing

Only
membranes

observed
2 not

bronchioles

found

pearance

Pneumonia
Hyaline

Diseases
of
the Chest

STRAUSS

blood

flow

of cardiac

dila-

affecting
the right
heart
that
obstruction
to pulis present.
of pulmonary

We

feel

it is

vessels

by

air.
nervous
system
a substantial

hemorrhage
number
of

was
cases.

FIGURE
6:
Swiss
cheese
pattern
of lung
due
to
overdistention
of terminal
bronchioles
and
atelectasis of distal
portions
of lung,
associated
with
interstitial inflammation
of
lungs.
(Hematoxylin
and
eosin,
x45)
(Full-term
infant,
weight
3460
gm.;
delayed
onset
of respiratory
distress;
survived
three
days.)

Voiume

October

46, No.
1964

This

may

anoxia

PULMONARY

have
of

and
drive

the

for

other

of

severe
anomalies
Eight
of them
had
of

or
resand

the

total

had

the
of

of

been

47

uniformly
rupture.

pand

the

to 30
lung.

easily

occur

sary

to invoke

and

over-vigorous

fully

to

occurs,

air

passes

peribronchial
the

into

dissection
In
the

tissue

septa.

of air

trifugal.

From

may

the

be

former

instance,

the

or both

mothorax.

here

thin

mediastinal
cavities

Upward

tinuous

the

of the

leads

to

from

the

pneumoperitoneum.
of air

rays

and

face

is manifested

ture

of

along

interlobular
such

septa

blebs

pneumothorax

to the

by subpleural
is the

lung

sur-

second

in pulmonary

Rup-

cause

interstitial

em-

physema.
that

of

necropsy

pulmonary

the

newborn

or

abnormal

material

interstitial
usually

in

Normal,

aerated

lungs

are

rupture

unless

subjected

intra-alveolar
iological

emphysema

develops

lungs.

indicates

nQt

prone

pressure
far
limits.
Pressures

in

uniformly
to

internal

to extremely
exceeding
required

Downloaded From: http://journal.publications.chestnet.org/ on 12/05/2014

high
physto cx-

previously
be-

beds

importance
as

is

re-

of hypo-

this

condition

incidence

is

of

anomalies

other

incompat-

of prematurity

in the

causation

interstitial
Emery6

has

shown

that

are

more

prone

to develop

full-term

infants

pulmonary

emphysema

interstitial
Our

half

is not

emphysema

findings

weighed

hand,

than

confirm

over

Landing

prematurity

this

3000
and

lusty,
pre(more

gm.).

On

the

Lubchenko4

as a common

im-

pre-exist-

state.

The

relationship

sema

is less well

disease

and

edema

pulmonary
and

hemorrhage,
activity

monary
interstitial
spontaneously
or
expert

pulmonary

interstitial
Neonates

are

likely

resuscitation.

intracranial
and

the

to de-

emphysema.
develop

edema

with

pulmonary

not

with
anoxia
to

emphy-

causing

interstitial
infants

hemorrhage
respiratory

altered

understood.

heart

Contrariwise,
nary

of

to pulmonary

congenital
velop

diseased

emphy-

the

disproportion

a high

clear.

congestion

Review

prone

survival.

circulation
of

be

entirely

ing

blebs.

particularly

is trivial

role

plicate

bronchovascular

can

of pulmonary

other

Centrifugal
the

limits

alveolar

developmental
with

than

mediastinum

Sponsufficient.8

interstitial

and

with

matures.

produces

emphysema.

tracking

dissection

the
con-

neck

subcutaneous

Downward

from

rupture.

that

clinical

lungs

The

into

ventilation

are

are

again

The

serious

pneu-

of

volumetric

associated
ible

pleura

anatomically

planes

appears

bronchial

plastic

break

to cause

can

neces-

techniques

efforts

pulmonary

It

and

travels

may

dissection

into
fascial

so-called

it

pleural

mediastinum

air

cases

lungs

develop

sponsible.

mediastinal

artificial

to acceptable

Hypoplastic

and

or cen-

rupture

resuscitative

adherence

de-

It is not

areas.

all

at

well

may

harmful.24

tween

locations,

causing

From

through

sheaths

these

centripetal

mediastinum

emphsema.
one

perivascular

connective

interlobular

into

the

these

for

mentioned

emphysema

and

found

of pressure-volume

respiratory

sema.

interstitial

is patchy

alveolar

excessive

account

20
the

conditions

to alterations
in

from

rupture

zones

and

taneous
Even

are

the

pressure

resusci-

due

vary
to

aeration

to

relationships,

no clinical
that lungs
and

due
high

lung

sufficient

in which

necropsy,

to

pulmonary

lungs

421

infant

H20,

velop

DISCUSSION

When

normal

cm.

In

NEWBORN

with
lungs.

lungs
and
loose
the chest
and
ab-

domen.
While
such
cases
have
significance,
they further
indicate
to expand
to internal

IN

incomplete

failure
to breathe
sponrather
dramatic
emphyse-

matous
effects
on
mesenchymal
tissues

unable
prone

to the

birth,

incompatible
hypoplastic

infants

tated
because
taneously
with

EMPHYSEMA

measures.

cases

such

at

for inefficient
in aspiration

resuscitative

Frequently

due

distress

responsible
resulting

Thirteen
had
life.

secondary,

respiratory

primary,
piratory
need

been

INTERSTITIAL

alteration

extent

emphysema
follows
on

pulmothat

the

of
pul-

develops
heels
of

KIRSCHNER

422

CLINICAL

MANIFESTATIONS

AND

In

all

within

the
27

51

or

initial

layed

DIAGNOSIS

cases,

hours

gories
could
with immediate

symptoms

of birth.
be

and

after

(b)

are

major

cate-

(a)

those
distress

those

a variable

always

with

period

de-

of

ap-

Resuscitative

required

as there

are

Diseases
of
the Chest

STRAUSS

dysgenesis

calls

iner to the
hypoplasia.

frequent
concomitant
Sometimes
the renal

tion

may

the

present

Delayed
able

attention

as an

period

respiratory
distress
what
slower
rate.
is therefore

amniotic

by

meconium-stained

fluid.

and

Breathing
is labored,
irregular
and shallow
with
intercostal
retractions
and progressive

and
pneumomediastinum
emphysema
are the

anterior
ballooning
um. Tachycardia

ible

anosis,

especially

room

air,

oxygen
yields

atmosphere.
tenacious

um.

circumoral,

but

Bloody

due

of the chest
and
is uniformly
present.
may

Tracheal
mucus,
vernix

fluid

either

to

in

is

high

delivery

or

as a result
of massive
pulmonary
hemorrhage.
A weak
high-pitched
cry hints
of
intracranial
hemorrhage
of traumatic
or
anoxic
origin.
Tracheal
shift
and cardiac
displacement
may be present
in unilateral
pneumothorax,
but

may

be

neonate.
absent

difficult

Breath
on

the

and tympany
Auscultatory
be
be

detectable.
even
more

side
may
signs

chest
will
Hepatomegaly

of

diaphragm.
An abnormal

deformities)

the

small

pneumothorax.
percussion.
may
not

apparent.
due
to

may
but
if

configuration

of

progressive

present,
but
be exaggerated

true
by a

to the
the

partial,
oblique

tinal
lateral

emphysema
projection

terior
sternal

bulging
lucency.
thymus

or mediastinal
features
discern-

only

The

lack

may

Pulmonary

rarely
views

complete.
At times,
are necessary
to deWidening
spaces,
somereadily

The

goal
and

not
the
skin

may

appearance
seen

in

(facies,
renal

skeletal

agenesis

Downloaded From: http://journal.publications.chestnet.org/ on 12/05/2014

by
or

can

be

occurred.
shadows
folds
AND

of treatment
cardiac

or effective

the
an-

retroview,
wid-

represent
atelectasis
and

seen.

even
Pleural

It is important
cast by axillary

from

pneumothorax.

TREATMENT

is efficient

function.

respiratory

pulmo-

Initially

should
be cleared
of foreign
gentle
suction.
In the absence

taneous

in
by

and

dilatation

airway

as

seen
on
medias-

or

elevated

Cardiac

PROPHYLAXIS

nary

collapse

sternum
with
posteroanterior

appear

enlargement

pectoral

den-

lung.

of the
In the

effusions
have
to distinguish
and

cannot

of contrasting

is best
visualized
and is manifested

congestion.

hepatic

forerunner,

emphysema,

ened.
Pulmonary
infiltrations
pneumonia,
hyaline
membranes,
or

common

Pneumothorax

times
noted
clinically,
are
the film.
Pneumomediastinum

right
the

more

a mantle
pneumothorax.
bulging
of the intercostal

the
or

pneumothorax
to diagnose,

a ballooned
be

in the
diminished

be noted
on
of pneumonia

heart
failure
is often
size of the liver
may
low

detect
are

Bilateral
difficult

it is extensive,
the

to

sounds

due

mediasfailure

of symptoms.

examination.

within

tect
and

or
are

of

to the
because
emphy-

Cardiac

duration

interstitial

is usually
multiple

obtained,

during

x-ray

be seen
sities

suction
often
or meconi-

sometimes

aspiration

in

on

radiologic
degree

proportion
probably
interstitial

Diagnosis:

pulmonary

resuscitative

and
The

of

enlargement

of longer

Radiologic

is common

disappear

hepatic

because

sternCy-

since

and pneumomediastinum
emphysema
as well.

Signs
of difficulty
are frequently
noted
just following
the first spontaneous
breaths
or upon
the heels of resuscitative
measures.

a variwell-being,

and at a somedeliberate
assess-

possible

sema
tinal

evidenced

Following

measures
are
less urgent,
study
can
be employed.

ing

exam-

mass.

apparent

develops
More

no spontaneous
respiratory
efforts
or merely
ineffectual
gasps.
Many
of these
cases have
been
heralded
by signs
of fetal distress
dur-

the

pulmonary
malforma-

abdominal

of

dyspnea
is often
out
size of the pneumothorax
it is due
to pulmonary

labor,

of

Group:

Onset

initial

ment

parently
normal
respiration.
Immediate
Onset
Group:
measures

appeared

Two

distinguished:
onset
of respiratory

apnea;

onset

AND

the

material
of spon-

efforts,

arti-

Volume
October

46, No.
1964

ficial

support

PULMONARY
including

vices
and
be employed.

INTERSTITIAL

breathing

That

gravate

pre-existent

emphysema
duce
it

in

such

must

measures

may

pulmonary

ag-

interstitial

Somebe pro-

duced
during
these
Antibiotics
should

maneuvers
(case
be administered

M.O.).
routine-

ly

premise

sound

infection
indicated

is frequently
in cardiac

given

promptly.

In

that

most

cases,

we

feel

should
be treated
of closed
thoracotomy
drainage
(case
C.G.).

thorax

means
water
has

been

we

do

reported
not

not

control

may

cause

with

advise
a

further

use

trauma

to

the infants
condition
is not
period
of careful
observation
ized
tion

during
of the

D.H.).
deflation

which
time
pneumothorax

On

If

desperate,
may
be

concomitant

one

a
util-

can

clinical

assume

that

the

un-

lies

and

constantly

tices

designed
fetal

in

good

prenatal

improving

obstetric

obviate

to

distress

or

the

intrauterine

for
spontaneously
interstitial
emphysema
its precipitation
by

developing
may
artificial

D.H.
ered
ean

3260

section.

fetal
taneous
suscitation

17,

gm.,
1955,

There

distress.

was

Breathing

and

occurred
was

carried

boy

low-flap

no

sign

and
immediately,

was

repeat
of

crying

deliv-

maternal
were
and

out.

Downloaded From: http://journal.publications.chestnet.org/ on 12/05/2014

sponno

re-

of

the

with

left.

In

but

mothorax

resorbed

plete

shift

addition,
not

be

ex-

of

the
carried

This

im-

of

starting

was

out.

The

days,

is

an

pneu-

and

com-

and

infant,

was

with-

quickly

of the
because

good

Sec-

a prominent

responded

Aspiration
carried
out

relatively

de-

or resuscitation.

failure

feature

of

of pneumo-

full-term

heart

rapid

example

appearance
distress

right

and
its
therapeutic

hours

five

in a vigorous,

and

penicil-

pneumothorax

within

antecedent

clinical

14

not

spontaneous

ondary

vapor,
Substantial

ensued.

Comment:
thorax

oxygen,

within
was

recovery

out

of

digitalis.

Aspiration

to

pneumothorax
of the vigor

condition

of the

response
to the
regimen,
particularly

infant

rest of the
digitalis.

CASE

This

boy,

month

after

weighing

spontaneous
cried

by
onset

at
In

active,

the

with

15

followed

by

pirations,

of

age,

Breath
occasional

the

and

Twenty
cavity

some

temporary

but

the

and

steadily,

right

upper

50

for

condition

left

ml.

underwater

of

air

air,
were

drainage.
from

the

leak.
in

There

breath

deteriorated
30

ad-

the
tubes

bubbling

it ceased

lobe.

were
birth,

of

improvement
and

pneumothorax

after

a continuous

infants

base.

Polyethylene

continuous

the

posteriorly

right

aspirated

bilaterally

resof

chloromycetin

improvement.

indicating

grunting

distant

the

hours

was

grasp.

ballooning

bilateral
of

was
vigorous
appeared,

rapid

visible

at

density

penicillin

tube,

and

cyanosis

revealed

increased

was

reflex

became

rales

film

There

Moro
dusky
cry,

sounds

cyanosis

resuscitation
was

and

born

breathed

baby

high-pitched

retractions

chest.

no
the

a good

hours

He

circumoral

but

nursery,

was
presentation

labor.

Slight

birth,

gm.,

vertex

of

immediately.

present

At

2250

prematurely

inserted
or

or

film

could

and

considered,

and

Cesar-

pneumothorax
X-ray

the

consisted

ministered,

full-term,
by

tachywithin

pneumothorax,
to

occurred

pleural
This

right

made.

right

tetracycline

without

October

left.

Marked
developed

pneumothorax

Treatment
lin,

X-ray

CASE

a
left

with

REPORTS

of

was

Oxygen,

CASE

the

diaphragms,

cluded,

and

pulmonary
also
provoke
means.

absent

on

of both
liver

diagnosis

employed.

infection.

he
and

almost

distended.

mediastinum

was

careful
and
that
the
responsible

were

diminished

enlarged

showed
the

and

development

Resuscitation
must
always
be
gentle
with
constant
awareness
morbid
conditions
of the lungs

clinical

R.S.:

prac-

suddenly

respiration

hours.

one

care

and
was

an

digitalis.
was not

pulmonary
disease
itself is responthe symptoms
(case
R.S.).

Prophylaxis

of

lung.

when

retraction

abdomen

layed
it

hours,
sounds

side

and

digitalis.

spontaneous
absorpmay occur
(case

without

improvement,

the

423

grunting

marked

provement

the other
hand,
when
adequate
of the pleural
space
has been
ac-

complished
derlying
sible for

is
be

15

Breath

right
was

marginal

and

the

the

of

as it can-

leak,

distress.

aspiration,

air

for

bronchostenosis

aggressively
by
with
underWhile
success

its routine
continuing

on

few

pneumo-

needle

of

cardia

as well.

that

cry

and

pulmonary

is given

well

cyanosis,

chest

present.
Digitalis
failure
and should

Oxygen

did

There

in some babies
or actually
proothers
with
the corresponding

the

IN NEWBORN

developed

pathologic
substrate
is recognized.
times
extensive
pneumothorax
may

on

He

de-

positive-pressure

mouth-to-mouth

EMPHYSEMA

hours

right
was
sounds
rapidly

after

birth.

KIRSCHNER

4q24

Necropsy:

Bilateral

momediastinum
present.
The
The

lungs

right

were

occupied

hyperemic.

The

structed.

lobes,

major

air

of

protein

or

blood

exudate

cells

tained

was

seen.

exudate

lung

and
Pulmonary

sparse and
enterococcus.
the

This

features

classic

red

activity
required

con-

mixture

case
which

we

manifestations

etiology
pulmonary

and

morbid
interstitial

newborn.

Therapy

in such

a situation

developed

of

the

yielded

to

can

only

unless

be

the

the

supportive
way

can

bronchiolar

baby

born

after

40

1959,

after

a seven

labor,

vertex

livery.

His

250

mg.

mine
a

of

weeks

weighing
on

one-half

presentation

50

mg.

was
12,

mid-forceps
1.0

promethazine

dea

total

mg.

hour

(Nalline)

was

Ten

given

just

mg.
before

The

infant

conium.

was

He

intubation

was
was

tioned,

and
At

noted,

this

and

twice,

air

was

was

Rapid

improvement
caused

ml.

mycetin
charged
chest

home
x-ray

diate-onset

of

bilateral

air

each

time.

from
of

through

plugging

she

was

of

the

02,

pneu-

the

right

hemi-

both

sides

of

tetracycline.

left

The
11th

day

the

tubes.
setback

tube.

Other
was

appeared.
to

be

Downloaded From: http://journal.publications.chestnet.org/ on 12/05/2014

to

have

and

later
of

the

The
marked.

over

the

measures,

was

and

res-

was

en-

The
next

infants
24

including
vapor

was

chest

liver

was

hours,

digitalis,

and

hyaline

ir-

expiratory

expansion,

shallower.

diagnosis

lung

became
and

hours

chloromycetin,

clinical

and
good

respirations

deteriorated

penicillin,

ges-

cyanosis,

color,

retraction

supportive

sec-

weeks

retractions.

tachycardia

condition

was

immediately

good

position

became

girl

circumoral

hour,

gm.
Cesarean
37

cried

intercostal

Three
in

2430
by

slight

intercostal

noted

X-ray

film

thorax

with

a shift

of

left

ply

of
40

the

the

chest

per

oxygen.

The

syn-

membrane

air,

heart

a few

Comment:

days.

and
The

was

left

of

a left

pneumothorax

drainage

and
of air

sup-

mild

controlled

was

continuous
expanded

gm.

a week.

developed

hour
child

by

of birth
of

a dia-

course
was
management
means

continuous

from

and
right.

thoracostomy

distress
one-half

2430

the

within

betic
mother.
The
downhill
promptly
reversed
by effective
thoracostomy

lung

lung

complete

within

37-week,

pneumo-

the

inexhaustible

There

Respiratory

spontaneously

left
to

tube

drainage

Recovery

this

an

accordingly

established.

for

of

mediastinum

yielded

and

was

collapse

and

underwater

suction

revealed

cent

thoracentesis
of

dis-

SUMMARY

The
exemplifies
the
In this
instance,

inter-

a patent

of

tube

underwater
fistula.

AND

CONCLUSIONS

normal

film.

This
group.

after

chloro-

baby
with

continuous

after

and

one-half

grunt

mother

for

no

and

larged,

1960,

anesthesia,

noted

Within

in

Seventy

penicillin,

25,

breathed

and

regular,

was

bilateral

developthera-

failed.

diabetic

Except

promptly.

aspirated

A temporary

vapor,

the

chest

was

drainage

on

the

by

by tubes

had

spinal

bubbling

respiration

of

She

with
suc-

spontaneous

chest

ensued.

and

was

left
of

me-

Tracheal

made

diagnosis

aspirated

by
included

baby

The

established

therapy

minutes.

bulging

Underwater

Comment:

ten

with

meconium

the

100

chest
was

covered

artificial

until

made.

yielding
of

for

time,

was

thorax.

apneic

a clinical

mothorax

limp,

accomplished,

out

gasps.

born

mouth-to-tube

carried

ml.

tation.

delivery.

was

under

vigorously.

dur-

period.

obtained

the
may

drome.

scopola-

(Phenergan)

one-half

of

that
alone

for the
prompt

chests

July

of

despite

spontaneous

received

(Demerol),

and

nalorphine

42,

gm.,

September

hour
and

aged

meperidine
three

2580

gestation
and

mother,

and

ing

boy,

was

On

pirations
This

respiratory

This
suggests
measures

aspiration

delivered

be
ob-

because
chest
did

spontaneous

of both

aeration

M.O.:

may

tion

underlying
in the

some

to overcome

be

struction.
CASE

effect

C.G.:

pathogenesis,

anatomy
emphysema

It

necessary
of the

been
responsible
pneumothorax.

mittent

practically

feel

feature.

by heavy
sedation
of
labor.
Artificial
mouth-

until

deflation
was

lung

included

prominent

developed.
resuscitative

peutic

bronchopneu-

of the

appear

not have
ment
of

lobes

emphysema

Culture

not

Surrounding

acute

caused
during

to-tube
respiration
was
of apnea.
The
ballooning

CAsE

Comment:
all

by

interstitial

scattered.

ducts
lower

debris.

showed

was

have
been
the mother

and
with

the

plugged

basophilic

unob-

precipitated

alveolar
in

were

parenchyma

monia.

by
mixed

Many

and

were

spaces

membranes.

bronchioles

firm

atelectasis

occasionally

hyaline

terminal

passages

air

3).

of

the Chest

blebs

were

extensive

potential

(Fig.

Subpleural

Diseases

STRAUSS

distress

were

dilated

which

Microscopically

obstruction

of

was
airless.

lower

pneu-

emphysema

heart
almost

both

and

pneumothorax

mediastinal

or

AND

immefetal

nary
born

precursors
interstitial
infant
have

and

sequelae

emphysema
in
been
described

of

pulmo-

the
newbased
up-

Volume
October

on

46, No.
1964

PULMONARY

observations

clinical

in

cases

necropsies

interstitial

a diseased

lung

hemorrhage,
volvement
inflation

despu#{233}s
de un

four

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or

La
muerte

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lung

an

Cnfasis

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en

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resuscitative
of an

subgroups

based

symptoms:

(a)

frequently

on the

the

sized

upon

the

death

tube

two
of

nouveau-ne,
autopsies
un

of

of

11

en

with
for

and

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les

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las

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Ia

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El
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Los
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dhy-

suffisants.

apparition

gravit#{233}
de
de

ischen

enfisema
un

zones

#{234}treLa condi-

rupture

fr#{233}quemment

apr#{232}s one

mort

bases

don
et

precursoras

pulmonar

bas#{225}ndose

de 47 autopSias
t#{243}rax.

des

atteinte

ZUSAMMENFASSUNG

caracterIsticas

enfisema

anor-

Une

respiratoires
les

sympt#{244}mes,

descrito

poumon

utilis#{233}es pour

d#{233}tresse sont

RESUMEN
han

un

semble

souvent

principaux,

La

secuelas

survient
aspiration,

alternance

forces

Cliniquement,

pneumothorax

sur

collapsus

provoquent

groupes

presented.

sur

n#{233}cessaire.

infants

emphasis

les

faites

interstitiel
ou

en

de

et

de pneumothorax.

(pneumonic,

at#{233}lectasie)

veau-n#{233} en

Aballi,
A. J., Moreno,
0.,
Beltran,
0.
S., Fontao,
J. A., Boudet,
L. and
Don
Varona,
A.:
Mediastinal
Emphysema
in the Newborn,
Rev.
Cubana
de
Pediat.,
26:629,
1954
(Abst.
in Radiology,
66:131,
1956).
Ten
cases
are
reported.
There
were
six fatalities,
all
of which
showed
aspiration
of amniotic
fluid
at necropsy.

Se

en-

interstitiel

observations

cliniques

pulmonaire

et

Alors

AODENDUM:

las

con

pr#{233}curseurs
pulmonaire

malade

mosaIque

perinflation

pneumothorax.

therapy

describe.

Ia

clinipor

d#{233}velopp#{233}(hypoplasie).

and

is empha-

seven

se

facteurs

4 cas

poumon

naire,

of

por

tratamiento

toracotomia

dapr#{232}s des
et

malement

period,

condition

de

Ia

lemphysCme

h#{233}morragie,

of

birth

destaca

neumot#{243}rax

plan

de

uso

d#{233}crit les
de

du

lion

this

Un

el

Lemphys#{232}me

main

onset

at

con

el neumot#{243}rax

47

suf-

of resuscitation,

thoracotomy

been

into

symptom-free

detectable

outline

upon

in-

are

afecci#{243}n se

infantes

discutible.

s#{233}quelles

respira-

time

heels

of

by

fall

immediately

gravity

clinically
An

cause

in distress

cases

esta

11

libre de sIntomas,

espont#{225}nea.

REsuME

sur

(b)
after
a variable
usually
spontaneously.
The

often

spontaneous

infant

variable

areas
of hyperto be the pre-

forces

rupture,

tory efforts
ficient.
Clinically,

has

de

Lauteur

While

425

manera

de 7 de

camente

Patchy

with
alternating
and collapse
appears

trapulmonary

peslodo

gravedad

aspiration,

(hypoplasia).

NEWBORN

de

abnormally

requisite.

with

IN

generalmente

atelectasis)

developed

and

EMPHYSEMA

of pneumothorax.

Pulmonary

in

47

INTERSTITIAL

zwei

dem
(a)

Haupt-

Zeitpunkt,
unmittelbar

Wiederbelebungs(b)

nach

einer

Zeitspanne,
dieser

Erkrank-

KIRSCHNER

426
ung
11

wird

beleuchtet

S#{228}uglingcn

mothorax.
mit

durch

mit

Umril3artige

Hervorhebung

drainage

Tod

von

festgestelltcn

Darstellung

der

wegen

den

klinisch

von

Therapie
mit

Saug-

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DECOSTA,

Howm,
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SALMON,
PORT,
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/.
6

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outflow
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mitral
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ADMINISTRATION
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The author
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blood
levels
of viomycin
by administering
it intravenously.
In his series
of 21 problem
cases
treated
by
this
method,
he obtained
good
results.
In 19
patients.
the viomycin
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with
PAS in an injectable
solution,
and
in the other
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massive
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of
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septum
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of the free
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9 JOANNIDES,
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