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
P
ULMONARY
has precursor
INTERSTITIAL
been of
astinal emphysema, pneumoperitoneum) tions.
A
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).
look
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
monary occasion
Sinai
normal
with
a
in
the
have
never
point
of
have
grouped strings
lungs
of
hand
lens
by will
interof the reveal
bronchovascular may
be
observed alveolar
for of
rays. seen
the torn
but
pneumothorax.
the
distribution
417
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Lack
on
subpleural
the air.
(Fig.
intrapul-
rupture,
the
1 indicates collections
is necessary
produced Examination
noted
responsible
Table
of
uncut spaces of air.’
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.5’8 Most extrapolated
to be the (medi-
pneumothorax a variety
complications the clinical
neonate
reports
in
be
EMPHYSEMA
shown by Macklin’ pneumomediastinum
of abof absolute
KIRSCHNER
418
TABLE
I.Pulmonary
1-DISTRIBUTION
interstitial
emphysema:
Bilateral
17
Unilateral
10
Focal
6
Location 2.
not
stated
a.
with
(L
34
7
COLLECTIONS
or
mediastinal
2
without
pneumomediastinum
Bilateral
pneumothorax:
Bilateral or
mediastinal
0
pneumothorax:
4
b.
with
or
mediastinal
pneumothorax:
without
emphysema: emphysema:
between
mediastinal
emphysema
indicates
that
directly
into
pleural
of
subpleural space
piratory
Unilateral interstitial
pulmonary emphysema:
0
Unilateral
pulmonary
emphysema: 11
3
interstitial
emphysema:
2
Bilateral pneumothorax:
5
0
Bilateral pneumothorax:
0
or
cant the
blebs
cause
of pneumothorax
classic
tinum
is a signifi-
0
Cases
Unilateral
Severe anterior pneumomediastinum emphysema and bilateral pneumotho-
elevation dilatation emphysema
0
pulmonary
circuitous
had
in addition
route
as emphasized
case
via
the
by Macklin.
unilateral
Four
of
the
11
one
interstitial
pneumomediastinum and
to
mediasOnly
pulmonary
emphysema
thorax.
rax. Note blebs, and interstitial well seen, 2250 gm.;
emphysema:
Bilateral
astinal
1:
pulmonary
interstitial
0
emphysema,
FIGURE mediastinal
Unilateral 2
pulmonary emphysema:
pneumomediastinum and pneumothorax
rupture the
emphysema:
Bilateral interstitial
pneumothorax:
correlation
pulmonary
interstitial
4 cases
Unilateral pneumothorax:
4
Unilateral
4
pulmonary
emphysema:
7
pneumothorax:
pulmonary
emphysema:
interstitial Pneumomediastinum a.
CASES
7 cases
emphysema:
Bilateral
interstitial
3.
34
only)
5
pneumothorax:
Unilateral
AIR:
R 3)
interstitial
b.
OF
Cases
pneumothorax:
Unilateral
Diseases the Chest of
Cases
(microscopic
pneuiiomediastinum
Bilateral
ABNORMAL
STRAUSS
1
II
Pneumothorax:
OF
AND
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.)
FIGURE
tures astinal gm.;
2: extending
Interstitial from
emphysema. with intrauterine
suscitation;
survived
emphysema pneumomediastinum (Full-term fetal
infant, distress;
one
one-half
and
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of
neck or weight required
hours.)
strucmedi3459 re-
Volume
46, No. 1964
October
3: blebs fetal
FIGURE
A few uterine
4
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
and
or
in
mucus,
vernix CLINICAL
death
resuscita-
when complete
the tree,
bronchi to
during
remained
in
larger prior
permit
2-GENERAL
was
too
removal.
it
It
caseosa
and
INFORMATION
CASES
21
Female
13 Male
Female
Total
gm.
3
3
6
3000-3499
gm.
5
4
9
2500-2999
gin.
4
1
5
2000-2499
gm.
3
3
6
2
8
Over
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)
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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
a
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
a
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
7
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.)
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Voiume
October
46, No. 1964
This
may
anoxia
4
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
to extremely exceeding required
internal 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 intracranial
and the
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21408/ on 01/29/2017
pulmo-
alteration
extent
emphysema follows on
resuscitation.
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.’2’4
tween
locations,
causing
From
through
sheaths
these
centripetal
mediastinum
emph’sema. 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
that 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
a
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
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
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21408/ on 01/29/2017
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
4
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 infant’s 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, out.
was
repeat of
crying
deliv-
maternal were and
sponno
re-
of
the
with
left.
In
but
mothorax
resorbed
plete
shift
addition, not
a
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.
2
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
of
air
air, were
drainage. from
the
leak. in
There
breath
deteriorated
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21408/ on 01/29/2017
left
ml.
underwater
30
ad-
the tubes
bubbling
it ceased
lobe.
were birth,
of
improvement and
pneumothorax
after
a continuous
infant’s
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-
a
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
1
CASE
a left
with
REPORTS
of
was
Oxygen,
CASE
the
diaphragms,
cluded,
and
pulmonary also provoke means.
a
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.
A
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-
a
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
a
appeared. to
be
to
have
and
later of
the
The marked.
over
the
measures,
was
and
res-
was
en-
The next
infant’s 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,
a
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
a
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
a
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.
A
delivery.
was
under
vigorously.
dur-
period.
obtained
the may
drome.
scopola-
(Phenergan)
one-half
of
that alone
for the prompt
A
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
3
M.O.:
may
4
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
a
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
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21408/ on 01/29/2017
of
pulmo-
the newbased up-
Volume October
on
46, No. 1964
4
PULMONARY
observations
clinical
in
cases
necropsies
interstitial
a diseased
lung
hemorrhage, volvement inflation
despu#{233}s de un
four
emphysema
or
La muerte
occurs
(pneumonia,
lung
an
Cnfasis
sobre
tubado
en
in-
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
tion
avec
que
les
les
efforts
el
las
del
reci#{233}n nacido,
des
sympt#{244}mes:
Ia
naissance,
et
(b)
El en
y de
de
7
pulm#{243}n
hemorragia, desarrollo tejido
para en
de
enfermo
esa
areas
Los el
mente en an
en
pour
en
rupturas
nacimiento
Die
tanto de
los
que
es del
alternantes
colapso.
que
las
espont#{225}nea
a
en
general-
fuerzas
entran esto
y
despu#{233}sde
en
Ic
nou-
deux
temps
sous-
d’appariapr#{232}s
apr#{234}s reanimation,
#{233}tat est
indemne
de
accentu#{233}epar
11 qui
sur
une
l’accent
sur
furent
La
atteints
detectable. esquisse
Ia
de
sonde
traitement,
apr#{234}s thoraco-
pneumothorax.
en (a) Ia
en ci
dos
tiempo
inmediatamente resucitaci#{243}n,
de
priny
al (b)
ciner
mit
Kollaps
Bezirken
gruppen zu
dem
bei
der
vcrsuch verschieden
lassen
Wicderbelebung Ruptur
sich
die
beginnen:
und den
von
h#{228}ufig den
F#{252}!3en folgend,
langen
gew#{246}hnlich spontan.
symptomenfreien Die
Schwere
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21408/ on 01/29/2017
f#{252}hren,
Kind
oft die
aus.
F#{228}lle in
ausgehend
Symptome
Geburt aus
Vorauassetzungen zur
Anstrengung
formen,
Affektio-
Ubcrblahung
befindlichen
respiratorische
die
cntwickelten
intrapulmonalen in Not
erkrank-
H#{228}morrhagie,
mit
d#{252}rften die
mit
W#{228}hrendBem#{252}hungen bei einem
einer
Fleckf#{246}rmige
oder
reicht
in
4 kIm-
pulmonale
krankhaft
vor.
seth.
Klinisch
subgrupos
in
alternicred
einer
Das
kommt
Neu-
aufgrund und
Aspiration,
(Pneumonic,
(Hypoplasie)
nen
zwar
Sketionen
Pneumothorax.
odcr
Lunge
eines beim
und
57
Emphysem
spontane
caus-
beschrieben
von
Lunge
Folgezustande Emphysems
an
Fallen
Atelektase)
empleadas menudo
und
werden
oft zu
respiratorias
sIntomas:
cet
Beobachtungen
ten
con
compromiso
resucitaci#{243}n
bas#{225}ndose los
d’un
imm#{233}diatement
interstitiellen
interstitielle
presenta
pulm#{243}n
areas
respiraci#{243}n
casos
rCanima-
g#{233}n#{233}ralement spontan#{233}e.
Anfangsstadien
pulmonalen von
intrapulmonares.
principales, de
el
y de Ia
divisent sur
(a)
pr#{233}sente Ic
geborenen
neumo-
aspiraci#{243}n, on
con
dificultades
maniobras
Cl’inicamente
cipio
en
Parece
condici#{243}n
de
bastan las
en
parchadas,
esfuerzos
infante
de
se
(hipoplasia).
inflaci#{243}n exagerada
se
cliniquement
mettant
tomie
observaciones
(neumonia, o
an#{243}malo
requisito
las clinicos
intersticial
atelectasia)
cas
p#{233}riode variable
pneumothorax
en
Ia
intrapulmo-
spontan#{233}s
nouveaux-n#{233}s
L’auteur
y
intersticial
en
casos
pulmonar
d’hy-
suffisants.
apparition
gravit#{233} de de
ischen
enfisema un
4
zones
#{234}treLa condi-
rupture
fr#{233}quemment
apr#{232}s one
mort
a
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
d’apr#{232}s des et
malement
period,
condition
de
Ia
l’emphysCme
h#{233}morragie,
of
birth
destaca
neumot#{243}rax
plan
de
uso
d#{233}crit les de
du
lion
this
Un
el
L’emphys#{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
L’auteur
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
7
festgestelltcn
Darstellung
der
wegen
den
klinisch
von
Therapie mit
Saug-
Pneumothorax.
8
2
3
4
E. of the Newborn 39:578, 1940. DECOSTA,
Howm, V. M. Pneumothorax /. Ped., 50:6,
SALMON, PORT, H.:
/. 6
Ped.,
Emphysema Medicine, “Spontaneous Infant,” Am.
Pneumothorax Obs. and Gyn.,
12
A. S.: “Spontaneous Ten Days of Life,”
13
AND
WEED,
in the 1957.
L. Pneumothorax 24:996,
LUBCHENCO,
taneous Pediatrics, 5
J.:
J.
“Recognition in Premature
of SponInfants,”
1959.
J.
L.:
“Interstitial
and
‘Airblock’
Lancet,
270:405,
1956.
mt.
S. R.: Med.,
11
DAVEN-
Infant,”
Emphysema, Pneuin the Newborn,”
“Experimental 24:332, 1919.
HYPERTROPHIC
Emphysema,
fant
INTRAVENOUS TREATMENT
14
N.
“Respiratory (Special
Y.
Difficulties Committee on
Panel
Discussion),”
State
J.
Med.,
in In-
ABRAMSON,
58:372,
1958.
C.
A. AND CHISHOLM, T. C.: “Intrapulmonary Pressures in Newborn Infant,” J. Ped., 20:338, 1942. DAY, R., GOODFELLOW, A. M., APGAR, V. AND BECK, G.: “Pressure-Time Relations in the Safe Correction of Atelectasis in Animal Lungs,” Pediatrics, 10:593, 1953. WILSON, J. L.: “Factors Involved in the ProSMITH,
Aids
of
Alveolar
Rupture
with
Mechanical
Respiration,” Pediatrics, 13:146, 1954. 15 GRUENWALD, P.: “Hypoplasia of the Lungs,” J. Mt. Sinai Hosp., 24:913, 1957. 16 LANDING, B. H.: “Pathologic Features of Respiratory Distress Syndromes in Newborn Infants,” Am. J. Roentgenol., 74:796, 1955. For 92nd
to
reprints, Street,
please
New
write York
Dr.
Kirschner,
2
East
City.
CARDIOMYOPATHY outflow pathways. Impaired function of ventricular muscle leads to restriction of inflow, and mitral regurgitation occurs in almost half the patients. There
is a
a possible symptoms
significant
familial
genetic basis. and signs of
incidence
Patients
either or restriction of effective diastolic has been discussed briefly. COHEN, J.. EFFAT, AND STEINE5, R.
Belt.
myopathy,”
ADMINISTRATION OF PULMONARY
The author reports that it is possible to get higher 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 was given in conjunction with PAS in an injectable solution, and in the other two
P.: Infants,
Ed.,
“The EtiEmphy-
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OBSTRUCTIVE
Previous experience of obstructive cardiomyopathy has been reviewed and amplified in the light of further hemodynamie and angiographic Investigations in 29 patients. Since obstruction is variable and hypertrophy constant, the term “hypertrophic” has been added to the definition. Hypertrophic obstructive cardiomyopathy is a generalized disorder of heart muscle in which massive hypertrophy of the ventricular septum and of the free wails of the ventricles frequently results in outflow tract obstruction. This obstruction to outflow is partly mechanical and partly due to abnormal behavior of the
Emphysema,”
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Vioe
Endoveineuse,”
