Brief History of Presentation

 
The patient was an African American infant born at 25 weeks gestation after premature rupture of membranes and premature labor.

Delivery

 
Upon delivery, the patient was responsive, initially with good respirations and oxygenation.

However, in minutes, he developed increasing oxygen requirements and apnea.

He was orally intubated.

A chest x-ray was performed to confirm position of the tip of the endotracheal tube.

This was found to be in the right mainstem bronchus.

The tube was pulled back approximately 0.3 cm.

Hospital day 2

 
Follow-up chest x-ray was performed.

The x-ray showed the tip of the endotracheal tube at the carina.

The x-ray also showed the development of right upper lobe “airspace disease.”

The endotracheal tube pulled back approximately 1.5 cm.

Hospital day 3

 
Follow-up chest x-ray was performed.

This showed increasing “airspace disease” in the right upper lobe and new, patchy disease in the rest of the lungs.

There was concern for right upper lobe collapse.

This was managed by progressive increases in the ventilator tidal volume; and by positioning the patient left side down (right side up).

These maneuvers achieved normal oxygen levels through the following day.

Hospital day 4

 
The patient underwent a trial of extubation.

He quickly decompensated.

An x-ray showed “complete opacification of the right hemithorax. There is diffuse airspace disease in the left lung as well. This is significantly worse than previously a day earlier.”

The patient was re-intubated.

The re-intubation was complicated by bilateral pneumothoraces.

He received additional life-saving measure, but died.