PERINATAL/NEONATAL CASE PRESENTATION Chest dynamics asymmetry facilitates earlier detection of pneumothorax D Waisman 1,2,6 , A Landesberg 3,6 , S Kohn 4 , A Faingersh 3 , IC Klotzman 5 , A Gover 1,2 , I Kessel 1,2 and A Rotschild 1,2 Pneumothorax is usually diagnosed when signs of life-threatening tension pneumothorax develop. The case report describes novel data derived from miniature superficial sensors that continuously monitored the amplitude and symmetry of the chest wall tidal displacement (TDi) in a premature infant that suffered from pneumothorax. Off-line analysis of the TDi revealed slowly progressing asymmetric ventilation that could be detected 38 min before the diagnosis was made. The TDi provides novel and valuable information that can assist in early detection and decision making. Journal of Perinatology (2016) 36, 157–159; doi:10.1038/jp.2015.172 INTRODUCTION Pneumothorax (PTX) is a life-threatening complication, with higher incidence in very low birth weight infants. PTX is usually diagnosed when signs of tension PTX develop, and when life- saving surgical drainage must be performed. The estimated median time delay from PTX onset to diagnosis and treatment is 127 min. 1 The prevalence of associated neurological complica- tions, such as intracranial bleeding or diffuse cerebral damage is high, with mortality rates as high as 43%. 2 Therefore, preventing the development of tension PTX is essential in order to avoid serious consequences. Our group has described the feasibility of monitoring the amplitude and symmetry of lung ventilation with three miniature motion sensors attached to both sides of the chest wall and to the upper abdomen. 3–5 These sensors sense the local chest wall tidal displacement (TDi), as well as the vibrations and breath and heart sounds. A 20% change in the TDi from the patient's established baseline TDi, measured by any of the sensors, defined a significant trend deviation. CASE We describe a case of a premature male newborn, second of twins, born at 32 weeks+3 days, with a birth weight of 1369 g. The infant initially received respiratory support by nasal continuous positive airway pressure, but later required mechanical ventilation, provided by high-frequency oscillatory ventilation (HFOV) and surfactant replacement therapy (Curosurf, Chiesi Pharmaceuticals, Parma, Italy). On day 1 of life, the newborn developed a left PTX and a chest-tube (CT) was inserted to drain it. On day 3, following parental consent, the baby was recruited to a feasibility study of TDi monitoring in our neonatal intensive care unit, (approved by the Carmel Medical Center institutional review board, CMC 0012-08, and registered at U.S. National Institutes of Health, NCT00702169). Three miniature motion sensors were attached to both sides of the chest and to the upper abdomen. The patient was monitored with the Pneumonitor (Pneumedicare, Yokneam, Israel) and recordings and printouts of the medical follow-up sheets were collected for off-line analysis. On day 3, the infant was stable while being ventilated on HFOV, the CT was clamped for 4 h, chest x-ray and transillumination were performed and were negative for free air, and the drain was removed. One hour later, blood-gas analysis revealed an increase in PaCO 2 from 39.8 mm Hg before the CT extraction to 50.5 mm Hg, while being ventilated with HFOV with 30% FiO 2 . Transillumination of the chest revealed a large PTX (Figure 1). Surgical drainage via a CT was performed, and successful drainage was validated by x-ray. Off-line analysis of the TDi from the moment of tube extraction revealed progressive development of asymmetric ventilation (Figure 2), significantly before diagnosis of PTX (denoted by ‘T’ in Figure 2). The TDi in the left chest, the side of the PTX, progressively decreased with a concomitant increase in the TDi in the contralateral right side. Overt asymmetric ventilation with a 20% increase in the right TDi developed 38 min before the diagnosis of PTX (denoted by ‘R’ in Figure 2). A 20% decrease in the left TDi was recorded 31 min before the diagnosis of PTX (denoted by ‘L’ in Figure 2). The abdominal sensor also revealed a progressive increase in the abdominal TDi, escalating to a 20% change from baseline 24 min before the diagnosis of PTX (denoted by ‘A’ in Figure 2). The changes in the TDi at the epigastric area may result from the increase in the PTX and larger tidal displacement of the diaphragm. It is important to note that diagnosis of progressing PTX via development of asymmetric TDis was performed in the presence of normal SpO 2 , and before development of cardiovascular decompensation. Two days later (on day 5), the baby was clinically stable and the endotracheal tube was removed, whereas the CT was left in place. In addition, he received high-flow therapy through a nasal cannula (Vapotherm, Stevensville, MD, USA). 1 Department of Neonatology, Carmel Medical Center, Technion—Israel Institute of Technology, Haifa, Israel; 2 Rappapport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel; 3 Faculty of Biomedical Engineering, Technion—Israel Institute of Technology, Haifa, Israel; 4 Pneumedicare Ltd., Yokneam, Israel and 5 Department of Neonatology, Mayer Children's Hospital, Haifa, Israel. Correspondence: Professor D Waisman, Department of Neonatology, Carmel Medical Center, Technion—Israel Institute of Technology, 7 Michal St, Haifa 34362, Israel. E-mail: dwaisman@netvision.net.il 6 These authors contributed equally to this work. Received 29 September 2015; revised 10 October 2015; accepted 15 October 2015 Journal of Perinatology (2016) 36, 157 – 159 © 2016 Nature America, Inc. All rights reserved 0743-8346/16 www.nature.com/jp