What are pearls regarding pulmonary interstitial emphysema (PIE)?

Updated: Jun 25, 2019
  • Author: Abhay J Bhatt, MD, MBBS; Chief Editor: Muhammad Aslam, MD  more...
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Keep the following pearls in mind:

  • Pulmonary interstitial emphysema (PIE) is a common comorbidity of neonates that is mainly associated with the etiologic triad of prematurity, respiratory distress syndrome (RDS), and mechanical ventilation therapy.
  • PIE is mainly a radiologic and pathologic diagnosis. It is associated with few clinical signs, but a progressive, sometimes rapid, increase in O 2 requirements, CO 2 retention, or hypotension are suggestive of this diagnosis.
  • The reported incidence varies widely depending on various factors such as gestational age, use of surfactant therapy, and different modes of mechanical ventilation. In the postsurfactant era, the reported incidence is between 3% and 8%. Clinical research is needed, with a specific emphasis on the incidence of, and outcomes in, PIE in the current era of innovative ventilatory strategies.
  • Although prematurity—the primary risk factor for PIE—is nonmodifiable, attention must be given to judicial treatment of RDS with early administration of surfactant and optimal use of mechanical ventilator support. An often-used strategy is to reduce the inspiratory time and/or decrease pressure along with adjusting the positive-end expiratory pressure (PEEP) enough to stent the airway will allow better emptying of the alveoli during expiration. [1] Close clinical observation by monitoring oxygen need, work of breathing and perfusion status, as well as judicious analysis of blood gas and chest x-ray, are essential to determine an optimal PEEP for a particular infant.
  • Consequences of PIE can be other air leak syndromes, such as pneumomediastinum, pneumothorax, or penumopericardium, if not enough attention and management strategies are applied.
  • If PIE develops, various management strategies include lateral decubitus positioning, selective main bronchial intubation and occlusion, and lobectomy for unilateral cases. Studies has shown the benefit, safety, and effectiveness of high frequency jet and oscillatory ventilation; it is been shown to reduce the peak airway pressure (P IP) and mean airway pressure (MAP) requirements to achieve the same oxygenation and ventilation goals.

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