Air leaks are among the most concerning and scary complications we face in the NICU—requiring both keen observation and swift response. Let’s explore the types of air leaks, why our tiniest patients are at risk, what nurses can do in moments of crisis, and why our role truly matters. 💙

What Types of Air Leaks Are Seen in the NICU? 🩺

NICU infants may experience several kinds of air leaks:

• Pneumothorax: Air enters the pleural space and compresses the lung, making breathing difficult.

• Pneumomediastinum: Air collects in the mediastinum, often showing a “spinnaker sail” sign on chest X‑ray.

• Pulmonary interstitial emphysema (PIE): Air escapes into lung tissue, disrupting gas exchange.

• Pneumopericardium: Rare but serious—air around the heart can affect cardiac output. 😟

Here is an X-Ray of a tension pneumothorax. Notice how the heart is being shifted to the babies left side. What signs do you think you would see in this baby?

Pediatric Imaging, 2020

Why Are Neonates Particularly Vulnerable? 🍼

Our patients are especially at risk because:

• Their lung tissue—particularly in preterm infants—is fragile.

• The thin pleural membranes are easily disrupted.

• Tools like CPAP or ventilators, while lifesaving, increase pressure in delicate lungs predisposing their risk of injury.

• Conditions like Respiratory Distress Syndrome result in uneven lung compliance, creating areas of overdistention.

Signs of an Air Leak 🚨

Early recognition of air leaks can make all the difference. Watch for these red flags:

• Sudden respiratory distress: Rapid breathing, grunting, flaring, or increased oxygen needs.

• Asymmetrical chest movement: One side not expanding fully—especially with pneumothorax.

• Heart rate/blood pressure changes: Bradycardia, tachycardia, or poor perfusion.

• Diminished breath sounds: Reduced or absent on one side during auscultation.

• Soft‑tissue swelling: Facial, neck, or chest swelling may suggest subcutaneous emphysema.

• Transillumination: A quick bedside tool we may use for IV starts can also be helpful to identify a pneumothorax!

Staying alert to these signs is key to early intervention and better outcomes.

Notice in the image below how the whole chest is glowing when the transilluminator is placed against the chest. This can be a great tool when you suspect there may be a pneumothorax.

Gupta, A & Dirnberger, D, 2020

The Most Common Air Leak: Pneumothorax 🌟

Pneumothorax stands out as the most frequent air leak in the NICU, often affecting very low–birth-weight infants on respiratory support. Sign of a pneumothorax include respiratory distress, tachycardia, tachypnea, a shift in the point of maximal impulse, or a increased oxygen requirement. Fast recognition is essential.

How Can NICU Nurses Be Prepared? 🛡️

Through careful preparation and teamwork we make a lifesaving difference:

• Vigilant monitoring: I remember monitoring a little boy on CPAP, whose was unusually restless, and was have frequent desaturation. oxygen saturation dropped unexpectedly. I noticed his chest was moving in an abnormal asymmetric pattern—indicating a possible pneumothorax.

• Swift communication and escalation: I alerted the team, who immediately ordered a stat chest X‑ray and supplies for a thoracentesis.

• Procedural support: I helped set up the supplies and supported the neonatologist who performed the needle thoracentesis.

• Post‑procedure care: After the thoracentesis, I closely monitored the baby and he was breathing much easier.

• Family education and support: The baby's parents were understandably frightened. I explained what was happening and checked in frequently to update and reassure them. When I finally saw their relief, I knew my presence mattered. 🥰

🌟 Elevate Your Expertise: Join The Air Leak & Chest Tube Webinar

If you're a NICU nurse or clinician, I invite you to join my webinar “Air Leaks and Chest Tubes in the NICU” on Saturday, June  28. We’ll dive deeper into recognizing air leaks, best practices for chest tube care, and ways to provide families with both competence and compassion. Register now to empower your practice—and save more little lives. 🙌

Sign Up Here

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References:

Pediatric Imaging. (2020). Premature newborn with respiratory distress on a ventilator. Retrieved from https://pediatricimaging.org/2020/11/19/premature-newborn-with-respiratory-distress-on-a-ventilator-9/ on June 15, 2025

Beaton, A., Sendi, P., Martinez, P. A., & Totapally, B. R. (2024). Prevalence and outcomes of air leak syndrome and subtypes in neonates in the United States. Journal of neonatal-perinatal medicine, 17(6), 846–857. https://doi-org.mlprox.csmc.edu/10.1177/19345798241308491

Jhaveri, V., Vali, P., Giusto, E., Singh, Y., & Lakshminrusimha, S. (2024). Pneumothorax in a term newborn. Journal of perinatology : official journal of the California Perinatal Association, 44(4), 465–471. https://doi-org.mlprox.csmc.edu/10.1038/s41372-024-01899-2

Cagle K. J. (2014). Pneumomediastinum in the neonate. Neonatal network : NN, 33(5), 275–282. https://doi-org.mlprox.csmc.edu/10.1891/0730-0832.33.5.275

Gupta, A., & Dirnberger, D. (2020). Thoracostomy. In MacDonald’s Atlas of Procedures in Neonatology Sixth Edition. LIPPINCOTT WILLIAMS & WILKINS.