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Tension pneumopericardium in an infant with acute respiratory distress syndrome

Open AccessPublished:July 04, 2020DOI:https://doi.org/10.1016/j.pedneo.2020.05.010
      A 2-month-old male infant was admitted to the Pediatric Intensive Care Unit for severe pneumonia caused by influenza virus. The patient developed an acute respiratory distress syndrome and was intubated (Fig. 1A). On the 4th day of mechanical ventilation, as the patient was ventilated using pressure-controlled continuous mandatory ventilation, he experienced severe bradycardia and oxygen desaturation requiring cardiopulmonary resuscitation. The chest radiograph showed a “halo sign” and a reduction in the heart size, which are findings consistent with tension pneumopericardium (Fig. 1B). Hemodynamic stability was restored after percutaneous pericardial drainage was performed.
      Figure 1
      Figure 1Chest radiographs performed 4 days apart in an infant undergoing mechanical ventilation for acute respiratory distress syndrome. (A) Day of tracheal intubation. (B) Four days later, the patient experienced cardiac tamponade. The chest radiograph showed a tension pneumopericardium. The reduction of the cardiac shadow illustrates the compression of the heart caused by accumulation of free air in the pericardial sac.
      Pneumopericardium is a rare but potentially life-threatening condition. Spontaneous pneumopericardium has been reported but in most cases is associated with positive-pressure ventilation.
      • Bonardi C.M.
      • Spadini S.
      • Fazio P.C.
      • Galiazzo M.
      • Voltan E.
      • Coscini N.
      • et al.
      Nontraumatic tension pneumopericardium in nonventilated pediatric patients: a review.
      ,
      • Roychoudhury S.
      • Kaur S.
      • Soraisham A.S.
      Neonatal pneumopericardium in a nonventilated term infant: a case report and review of the literature.
      The exact pathophysiology of pneumopericardium is unknown. Pneumopericardium is believed to occur because of an increase in the intra-alveolar pressure, leading to a rupture of the alveolar walls. Free air dissects along the peribronchial spaces toward a site of potential weakness at the reflection of the visceral and parietal pericardium near the ostia of the pulmonary veins.
      • Roychoudhury S.
      • Kaur S.
      • Soraisham A.S.
      Neonatal pneumopericardium in a nonventilated term infant: a case report and review of the literature.
      ,
      • Cools B.
      • Plaskie K.
      • Van de Vijver K.
      • Suys B.
      Unsuccessful resuscitation of a preterm infant due to a pneumothorax and a masked tension pneumopericardium.
      The air accumulating between the two pericardial layers can compress the heart, resulting in hemodynamic instability. Diagnostics is confirmed by chest radiograph. The classical finding is a band of air completely surrounding the heart and resulting in a radiolucent halo.
      • Maxson I.N.
      • Chandnani H.K.
      • Lion R.P.
      The heart's halo: caring for pediatric pneumopericardium.
      Pneumopericardium can be associated with other air-leak syndromes such as pneumomediastinum, pneumothorax, and subcutaneous and interstitial emphysema. The clinical signs of pneumopericardium vary from asymptomatic to the presence of cardiac tamponade. If the case is asymptomatic, pneumopericardium can resolve spontaneously, and close monitoring of the patient would be sufficient.
      • Bonardi C.M.
      • Spadini S.
      • Fazio P.C.
      • Galiazzo M.
      • Voltan E.
      • Coscini N.
      • et al.
      Nontraumatic tension pneumopericardium in nonventilated pediatric patients: a review.
      ,
      • Roychoudhury S.
      • Kaur S.
      • Soraisham A.S.
      Neonatal pneumopericardium in a nonventilated term infant: a case report and review of the literature.
      In case of the presence of hemodynamic instability, immediate decompression of the pericardial space with pericardiocentesis is required. For this procedure, the subxiphoid approach is preferred.
      • Kharrat A.
      • Jain A.
      Guidelines for the management of acute unexpected cardiorespiratory deterioration in neonates with central venous lines in situ.
      After skin disinfection, the needle is inserted between the xiphoid process and the left costal margin at an angle of 30° to the skin and is directed toward the left shoulder, while continuous aspiration is performed with a syringe. For recurrent pneumopericardium, insertion of a pericardial tube may be necessary.

      Authors contributions

      Marc Tesnière: image preparation and drafting. Laszlo Kovacic and Nora Hedreville: revision of the manuscript. Jean-Marc Rosenthal: revision and oversight. All authors have read and approved the final manuscript.

      Declaration of Competing Interest

      The authors have no conflicts of interest relevant to this article.

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