Page 5 / Case 11.02
ANSWERThe fact that the SaO2 has increased to 97% on 100% O2 virtually excluded cyanotic heart disease. An echocardiogram confirmed a normal heart. The differential diagnosis we entertained was that of either a congenital diaphragmatic hernia or an eventration. There was discussion in the rounds, that the stridor could not yet be explained
MORE INVESTIGATIONS WOULD YOU DO AT THIS POINT TO RULE OUT SOME OF THEM?
CLINICAL PROGRESSOn day three the baby was transferred to our hospital for further investigation. On the second day in our hospital he was extubated, but he developed stridor for which he was given racemic epinephrine and dexamethasone. Then was put on CPAP via nasal prongs again. His PCO2 rose from 46 to 97 torr. He was reintubated within 2 hours for ventilatory failure.
CLINICAL PROGRESSENT was asked to evaluate him for stridor. Laryngoscopy and bronchoscopy were normal. The vocal cords had normal movements and there were no airway abnormalities. The next day (Day 9 of life ) a second extubation failed with stridor, high PCO2 , and high FiO2 requirements. He did not respond to CPAP, so was intubated for a third time, which was technically difficult.
the chest X-ray LEFT
Another chest X-ray while the baby is intubated shows the abnormal position of diaphragm on right. Eventration of the right hemi-diaphragm was considered most likely. Diaphragmatic ultrasound showed no movement of the right hemi-diaphragm and no herniation.
In summary, you have a 10 days old baby who failed extubation twice, and who was observed to have a normal larynx, normal lower airways and normal lung parenchyma, but a paralyzed and eventrated right diaphragm.
WHAT WOULD YOU DO NOW?