Neonatal pneumothorax from the perspective of a pediatric surgeon: classification and management protocol: a preliminary algorithm

Background/aimCurrent neonatal pneumothorax classifications based on air volume escaping in pleural space have no contribution on the treatment. Therefore, our aim was to classify neonatal pneumothorax to guide treatment management based on our experiences.Material and methodsThe records of all neonates admitted to our clinics from March 2017 to August 2020 were reviewed. The patients with pneumothorax were identified through the neonatology department patient database search. The study only included the patients with symptomatic pneumothorax and these patients were evaluated into 3 groups based on the changes in peripheral oxygen saturation (SpO2) and clinical features immediately after the tube thoracostomy (TT) procedure. Accordingly, neonatal pneumothorax was divided into 3 types: patients with SpO2 increasing immediately after TT were included in type I, patients whose SpO2 did not change after TT were included in type II, and patients with SpO2 decreasing immediately after TT were included in type III pneumothorax.Results A total of 82 patients were included in the study. Sixty-one percent of these patients had type I, 24% had type II, and 15% had type III pneumothorax. None of the neonates died in type I and II pneumothoraces while 9 of 12 neonates (75%) died within the neonatal period in type III pneumothorax. Although we applied treatments such as high-frequency oscillatory ventilation, selective intubation, continuous negative aspiration, and surgical treatment to our patients that were lost due to type III pneumothorax, we were not successful. We successfully managed our surviving type III pneumothorax patients with a simple pressure cycle ventilator, using a combination of high rates, modest peak airway pressures 18 to 22 cm H2O and no positive end-expiratory pressure (PEEP)], and an autologous blood patch.Conclusion Classification of pneumothoraces into different types significantly contributes to patient treatment planning through a predetermined strategy, not through trial-and-error. High frequency and zero PEEP ventilation can provide significant improvement in risky cases.