A 28-day-old male baby weighing 3.4 Kg was referred as a case of perinatal asphyxia with respiratory distress not responding to medical management.
On examination, baby was tachypnoeic with flaring of alae nasi and sub costal retraction. The pulse rate was around 150/min. On examination of the respiratorysystem, decreasedbreath sounds on the left hemi thorax was noted. On examination of the cardiovascular system, the heart sounds were shifted to the opposite side. No gross cardiac anomalywas found.
Following investigations were carried out: complete blood count, blood glucose, blood urea, serum creatinine and electrolytes and chest X-ray (PA and lateral view. Chest X-ray showed increased translucency onthe left side with tracheal and mediastinal shift to the right side. CT scan confumed the diagnosis of CLE of the left upper lobe (,).
Fig 1 & 2
CT thorax showing hyperlucent, hyperexpanded left upper lobe causing compression of the remaining lung and mediastinal shift to right.
The neonate was posted for left upper lobectomy.
Preoperative examination revealed tachycardia and tachypnoea with signs of respiratory distress. On auscultation, there were decreased breath sounds on the left hemithorax. The cardiovascular system was normal. Oxygen saturation (SpO2) was 84% in air, but there was no visible cyanosis. Routine hematological and biochemical investigations were within normal limits. Echocardiography ruled out any associated congenital cardiac anomalies.
The baby was labeled as ASA III E. The baby was wrapped in warm cotton wool gamgees and placed on the heating mattress. Cardioscope and pulse oximeter was attached to the baby. Ryle's tube was aspirated with a syringe. Before starting anaesthesia, a surgeon was scrubbed to perform emergency thoracostomy if required.
Antisialogogue atropine 0.0lmg.kg−1 and fentanyl 3 mcg was given intravenously and rectal paracetamol suppository 80mg was placed. The baby was pre oxygenated for 5 minutes and then gradually sevoflurane was started. Gentle manual ventilation was performed via the facemask.
After introducing laryngoscope, a 3.5 size endotracheal tube was inserted. The baby was connected to anaesthesia machine through Jackson Rees modification of Ayre's ‘T-piece’.
Spontaneous ventilation was maintained using 100% oxygen, 1-2% sevoflurane with gentle manual ventilation. Saturation on pulse oximeter was 98% following intubation
The neonate was placed in true right lateral position
Monitoring included electrocardiogram, invasive blood pressure, SpO2, ETCO2 and rectal temperature. IV fluids were titrated according to Holiday Segar formula to replace fasting and maintenance requirements. Blood loss was replaced. Vital signs were maintained in normal range throughout surgery.
Once resection of the affected lobe was completed, controlled lung ventilation with atracurium as the neuromuscular blocking agent was started. Nitrous oxide was added thence.
Blood gases intraoperatively and postoperatively were within normal limits. At the end of operation, intercostal block was given with 3 ml of 0.125% bupivacaine, and residual neuromuscular block was reversed with neostigmine 0.15 mg along with atropine 0.03 mg IV. The infant was extubated when spontaneous respiration was sufficient to maintain SpO2>90% in air. Later, the child was kept in an oxygen-enriched environment in the pediatric intensive care unit under continuous SpO2 and EKG monitoring. At 72 hours the chest drain was removed after full expansion of the residual lung. Rest of the postoperative period was uneventful, and the child was discharged after 7 days.
Lung biopsy of the resected segment showed lung parenchyma with atelectatic changes and emphysematous dilatation of alveolar spaces in the surrounding zone. (,).
Gross specimen of the resected emphysematous left upper lobe.
Microscopy showing distended alveolar spaces.