Team Approach Yields Optimal Outcomes for Preterm Infant

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Neonatology Update

An ex 23-week male infant was delivered at a community hospital with a birth weight of 520g. He was intubated in the delivery room, received 3 doses of surfactant, and was treated with antibiotics for 7 days. He subsequently failed extubation x3 and remained on mechanical ventilation until day of life (DOL) 64 when he was extubated to NIPPV via the RAM cannula. However, he had difficulty weaning from NIPPV and therefore was transferred to CHOP on DOL 99 for further management of his chronic lung disease.

cta image Left: CTA image showing bilateral round lesions concerning for abscess. Right: Pus drained from the left lung lesion. At the time of transfer, he was on NIPPV with PIP/PEEP 30/10 cmH2O at rate of 40 via RAM cannula. He had significant work of breathing and tachypnea on this support. However, he was not on any supplemental oxygen. His admission chest X-ray at CHOP showed bilateral round opacities. Given this clinical picture of severe respiratory distress without oxygen requirement and unusual X-ray findings, we decided to intubate the baby for better respiratory support.

Two days after admission, the patient underwent ultra low-dose CT angiogram (CTA), which showed bilateral rounded opacities concerning for abscesses in addition to moderate chronic lung disease. After multiple discussions with infectious diseases (ID), pulmonology, radiology, and interventional radiology (IR), the decision was made for an aspiration biopsy by IR. A chest ultrasound (US) was therefore done to help aid the biopsy. The baby was taken to IR 4 days later and 5ml of pus was drained from the left lung lesion. He was placed on oxacillin right after the biopsy based on a previous history of MSSA tracheitis. The biopsy sample also grew MSSA and the baby was treated with oxacillin for a total of 2 weeks when he was successfully extubated to CPAP of 6. A repeat chest US 1 week after starting the treatment demonstrated resolution of abscesses bilaterally. His respiratory support was gradually weaned, and the baby was discharged home on ¼ L nasal cannula 4 weeks later.

This case highlights the importance of treating the underlying pathology. Taking advantage of the advanced diagnostic modalities such as ultra low-dose CTA available at CHOP and also the expertise of multiple specialties such as pulmonology, ID, radiology, and IR, we were able to come up with the best strategies to diagnose and treat the lung abscesses quickly and effectively. In this case, the rich experience and multidisciplinary collaboration of the NeoCLD Program resulted in significant improvement of the baby’s chronic lung disease.