Pneumatocele

Pneumatocele

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Pulmonary pneumatoceles are thin-walled, air-filled cysts that develop within the lung parenchyma. They can be single emphysematous lesions but are more often multiple, thin-walled, air-filled, cystlike cavities. Most often, they occur as a sequela to acute pneumonia, commonly caused by Staphylococcus aureus. However, pneumatocele formation also occurs with other agents, including Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli, group A streptococci, Serratia marcescens, Klebsiella pneumoniae, adenovirus, and tuberculosis. Pneumatoceles are generally observed soon after the development of pneumonia but can be observed on the initial chest radiograph.

Noninfectious etiologies include hydrocarbon ingestion, trauma, and positive pressure ventilation.

In premature infants with respiratory distress syndrome, pneumatoceles result mostly from ventilator-induced lung injury. [1, 2, 3]

In most circumstances, pneumatoceles are asymptomatic and do not require surgical intervention. [4] Treatment of the underlying pneumonia with antibiotics is the first-line therapy. Close observation in the early stages of the infection and periodic follow-up care until resolution of the pneumatocele is usually adequate treatment. The natural course of a pneumatocele is slow resolution with no further clinical sequelae. Invasive approaches should only be reserved for patients who develop complications.

Since the 1950s, multiple theories have been proposed as to the exact mechanism of pneumatocele formation; however, the exact mechanism remains controversial.

Carrey suggested that the initial event is inflammation and narrowing of the bronchus, leading to the formation of an endobronchial ball valve. [5] Ultimately, this bronchial obstruction leads to distal dilatation of the bronchi and alveoli. In 1951, Conway proposed that a peribronchial abscess forms and subsequently ruptures its contents into the bronchial lumen. [6] This also acts similarly to a ball-valve obstruction in the bronchus and leads to distal dilatation. In 1972, Boisset concluded that pneumatoceles are caused by bronchial inflammation that ruptures the bronchiolar walls and causes the formation of “air corridors.” [7] Air dissects down these corridors to the pleura and forms pneumatoceles, a form of subpleural emphysema.

Traumatic pneumatocele has a different pathophysiology from the infectious type, [8] developing in a 2-step process. Initially, the lung is compressed by the external force of the trauma, followed by rapid decompression from increased negative intrathoracic pressure. A “bursting lesion” of the lung occurs and leads to pneumatocele formation.

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Incidence of postinfectious pneumatocele formation ranges from 2-8% of all cases of pneumonia in children. [9] However, the frequency can be as high as 85% in staphylococcal pneumonias.

Although mortality from the initial pneumonia can be significant, mortality associated with pneumatoceles is quite low. Complete resolution without long-term sequelae is typical; however, rare complications can occur, including the following:

Tension pneumatocele

Pneumothorax

Secondarily infected pneumatocele

No specific racial predilection is observed for pneumatocele formation. Because pneumatoceles are usually a complication of pneumonia, the predilection is based on susceptibility for infection.

No sex predilection is known.

Infants younger than 1 year account for three fourths of the cases of staphylococcal pneumonia. Because pneumatoceles commonly develop as a complication of staphylococcal pneumonia, pneumatoceles are found more frequently in infants and young children. One study reported that 70% of pneumatoceles occurred in children younger than 3 years. [10]

Hussain N, Noce T, Sharma P, Jagjivan B, Hegde P, Pappagallo M, et al. Pneumatoceles in preterm infants-incidence and outcome in the post-surfactant era. J Perinatol. 2010 May. 30(5):330-6. [Medline].

Arora P, Kalra VK, Natarajan G. Pneumatoceles in infants in the neonatal intensive care unit: clinical characteristics and outcomes. Am J Perinatol. 2013 Sep. 30(8):689-94. [Medline].

Van Hoorebeke E, Jorens PG, Wojciechowski M, Salgado R, Desager K, Van Schil P, et al. An unusual case of traumatic pneumatocele in a nine-year-old girl: a bronchial tear with clear bronchial laceration. Pediatr Pulmonol. 2009 Aug. 44(8):826-8. [Medline].

Imamoglu M, Cay A, Kosucu P, et al. Pneumatoceles in postpneumonic empyema: an algorithmic approach. J Pediatr Surg. 2005 Jul. 40(7):1111-7. [Medline].

Carrey J. On the natural regression of pulmonary cysts during early infancy. Pediatr. 1953. 11:48-64.

Conway DJ. The origin of lung cysts in childhood. Arch Dis Child. 1951. 26:504-529.

Boisset GF. Subpleural emphysema complicating staphylococcal and other pneumonias. J Pediatr. 1972 Aug. 81(2):259-66. [Medline].

Galea MH, Williams N, Mayell MJ. Traumatic pneumatocele. J Pediatr Surg. 1992 Dec. 27(12):1523-4. [Medline].

Amitai I, Mogle P, Godfrey S, Aviad I. Pneumatocele in infants and children. Report of 12 cases. Clin Pediatr (Phila). 1983 Jun. 22(6):420-2. [Medline].

Kunyoshi V, Cataneo DC, Cataneo AJ. Complicated pneumonias with empyema and/or pneumatocele in children. Pediatr Surg Int. 2006 Feb. 22(2):186-90. [Medline].

Shamberger RC, Wohl ME, Perez-Atayde A, Hendren WH. Pneumatocele complicating hyperimmunoglobulin E syndrome (Job’s Syndrome). Ann Thorac Surg. 1992 Dec. 54(6):1206-8. [Medline].

Schimke LF, Sawalle-Belohradsky J, Roesler J, Wollenberg A, Rack A, Borte M, et al. Diagnostic approach to the hyper-IgE syndromes: immunologic and clinical key findings to differentiate hyper-IgE syndromes from atopic dermatitis. J Allergy Clin Immunol. 2010 Sep. 126(3):611-7.e1. [Medline].

Hussain N, Noce T, Sharma P, Jagjivan B, Hegde P, Pappagallo M, et al. Pneumatoceles in preterm infants-incidence and outcome in the post-surfactant era. J Perinatol. 2009 Oct 8. [Medline].

Zuhdi MK, Spear RM, Worthen HM, Peterson BM. Percutaneous catheter drainage of tension pneumatocele, secondarily infected pneumatocele, and lung abscess in children. Crit Care Med. 1996 Feb. 24(2):330-3. [Medline].

Park TH, Kim JK. Nonsurgical management of an enlarging pneumatocele by fibrin sealant injection via pigtail catheter. Pediatr Pulmonol. 2016 Feb. 51 (2):E5-7. [Medline].

Fujii AM, Moulton S. VATS management of an enlarging multicystic pneumatocele. J Perinatol. 2008 Jun. 28(6):445-7. [Medline].

Levison ME, Fung S. Community-associated methicillin-resistant Staphylococcus aureus: reconsideration of therapeutic options. Curr Infect Dis Rep. 2006 Jan. 8(1):23-30. [Medline].

Al-Saleh S, Grasemann H, Cox P. Necrotizing pneumonia complicated by early and late pneumatoceles. Can Respir J. 2008 Apr. 15(3):129-32. [Medline]. [Full Text].

Asmar BI, Thirumoorthi MC, Dajani AS. Pneumococcal pneumonia with pneumatocele formation. Am J Dis Child. 1978 Nov. 132(11):1091-3. [Medline].

Chartrand SA, McCracken GH Jr. Staphylococcal pneumonia in infants and children. Pediatr Infect Dis. 1982 Jan-Feb. 1(1):19-23. [Medline].

Chitayat D, Diamant S, Lazevnick R, Spirer Z. Haemophilus influenzae type B pneumonia with pneumatocele formation. Clin Pediatr (Phila). 1980 Feb. 19(2):151-2. [Medline].

Hendren WH, Haggerty RJ. Staphylococcal pneumonia in infancy and childhood: Analysis of 75 cases. JAMA. 1958. 168:6-16.

Joosten KF, Hazelzet JA, Tiddens HA, et al. Staphylococcal pneumonia in childhood: will early surgical intervention lower mortality?. Pediatr Pulmonol. 1995 Aug. 20(2):83-8. [Medline].

Khan EA, Wafelman LS, Garcia-Prats JA, Taber LH. Serratia marcescens pneumonia, empyema and pneumatocele in a preterm neonate. Pediatr Infect Dis J. 1997 Oct. 16(10):1003-5. [Medline].

Knight GJ, Carman PG. Primary staphylococcal pneumonia in childhood: a review of 69 cases. J Paediatr Child Health. 1992 Dec. 28(6):447-50. [Medline].

McGarry T, Giosa R, Rohman M, Huang CT. Pneumatocele formation in adult pneumonia. Chest. 1987 Oct. 92(4):717-20. [Medline].

Quigley MJ, Fraser RS. Pulmonary pneumatocele: pathology and pathogenesis. AJR Am J Roentgenol. 1988 Jun. 150(6):1275-7. [Medline].

Schimpl G, Schneider U. Traumatic pneumatoceles in an infant: case report and review of the literature. Eur J Pediatr Surg. 1996 Apr. 6(2):104-6. [Medline].

Shen HN, Lu FL, Wu HD, et al. Management of tension pneumatocele with high-frequency oscillatory ventilation. Chest. 2002 Jan. 121(1):284-6. [Medline]. [Full Text].

Victoria MS, Steiner P, Rao M. Persistent postpneumonic pneumatoceles in children. Chest. 1981 Mar. 79(3):359-61. [Medline].

Al-Ghafri M, Al-Hanshi S, Al-Ismaily S. Two Cases of Pneumatoceles in Mechanically Ventilated Infants. Oman Med J. 2015 Jul. 30 (4):299-302. [Medline].

Denise Serebrisky, MD Associate Professor, Department of Pediatrics, Albert Einstein College of Medicine; Director, Division of Pulmonary Medicine, Lewis M Fraad Department of Pediatrics, Jacobi Medical Center/North Central Bronx Hospital; Director, Jacobi Asthma and Allergy Center for Children, Jacobi Medical Center

Denise Serebrisky, MD is a member of the following medical societies: American Thoracic Society

Disclosure: Nothing to disclose.

Arthur B Atlas, MD Assistant Clinical Professor, Department of Pediatrics, University of Medicine and Dentistry of New Jersey

Arthur B Atlas, MD is a member of the following medical societies: American Academy of Pediatrics, American Academy of Sleep Medicine, American College of Chest Physicians, American Lung Association, American Thoracic Society, Medical Society of New Jersey

Disclosure: Received grant/research funds from astra zeneca for none.

Debra Boyer, MD Fellow, Department of Pediatrics, Division of Pulmonary Medicine, Children’s Hospital of Boston

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Charles Callahan, DO Professor, Chief, Department of Pediatrics and Pediatric Pulmonology, Tripler Army Medical Center

Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women’s and Children’s Hospital of Buffalo

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Girish D Sharma, MD, FCCP, FAAP Professor of Pediatrics, Rush Medical College; Director, Section of Pediatric Pulmonology and Rush Cystic Fibrosis Center, Rush Children’s Hospital, Rush University Medical Center

Girish D Sharma, MD, FCCP, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Royal College of Physicians of Ireland

Disclosure: Nothing to disclose.

Pneumatocele

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