Presentation
Preterm neonate (23rd gestational week; delivered via C-section due to maternal infection and PROM) with insufficient spontaneous breathing.
Patient Data
Endotracheal tube with its tip just above the carina and hence, placed a little too deep.
The umbilical arterial line is malpositioned with a folded line in a large aortic branch, either in the right renal artery, SMA or celiac trunk.
Moderate ground glass opacification with bilateral central dominance. The cardiac silhouette remains visible as does the diaphragm.
Conclusion: mild to moderate IRDS with centrally located ground glass airspace and interstitial opacities with mild air bronchograms. Sub optimally placed lines and tubes.
The x-ray taken the next day shows the removal of the umbilical arterial line and the endotracheal tube and a newly inserted central venous line via the left brachial vein, its tip remaining in the subclavian vein, hence not centrally positioned.
Discrete progression of ground glass opacification with loss of visibility of the cardiac silhouette. Dilated small bowel loops in the upper abdomen, NGT inserted in the correct position.
The child went on to have a prolonged CPAP therapy for 42 days and intermittent high-flow oxygenation for another 5 days. Two months later, a control x-ray was taken because the child still suffered from abnormal respiratory function and shortness of breath which required permanent respiratory support.
X-RAY Findings: Bilateral ill-defined reticulonodular markings, more prominent on the right, with obscuration of the right hemidiaphragm and heart border, positive air-bronchograms and hyperinflation of the left lower zone. No apparent atelectasis. The widened upper mediastinum on the right is most likely due to non-centric projection (see trachea and clavicles). Dilated small and large bowel loops.
Conclusion: given the history of a preterm neonate with IRDS and consecutive prolonged oxygenation therapy and normal infection parameters (normal CRP and leukocyte count), the most likely diagnosis is bronchopulmonary dysplasia (BPD).
Case Discussion
The case illustrates a feared consequence of IRDS and consecutive high-pressure oxygenation in preterm neonates: bronchopulmonary dysplasia (BPD).
Clinically, this young fellow recovered quite well and was discharged from hospital some weeks later. The oxygen therapy could be reduced step by step from permanent to intermittent to zero and currently his medication is an inhaled corticosteroid. His lungs, however, will most likely suffer from some irreversible parenchymal damage.
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