This child had been admitted in critical condtion in our Pediatric ICU.

The child was in respiratory distress with decompensated shock.

After initial fluid bolus,vasopressors were started.

The child  was maintaining saturation of 96% on room air but at the cost of increased respiratory rate and chest retraction.

The child was intubated and put on mechanical ventilator, to save the respiratory muscles from becoming fatigued.

The child became comfortable with no chest retraction, with saturation of 98% on ventilator.

After  few hours,saturation  decreased to 70% and ventilator settings were escalated to maintain the saturation.

On chest X-Xray examination, there were complete collapse of left lung which was detected to be responsible for decrease in saturation.

Chest phsiotherapy was started and the repeat chest X-Ray after few hours was normal.

The cause of lung collapse was mucus plug ,obstructiing the left main bronchus which was cleared by chest physiotherapy.

KEY MESSAGE– When the child is on ventilator and saturation falls, percuss and auscultate the chest.

If percussion note is dull and breath sound is diminished on that side ,suspect collapse of lung and do chest X-Ray to detect it.

Apart from mucus plug ,if the Endotracheal tube is placed inadvertantly low so as to enter the right main bronchus, there will be collapse of the left lung and hyperinflation of the right lung.

The tip of the endotracheal tube should lie 1.5 cm above the carina in case of children, which correspond between T2 to T4 vertebrae. It should be checked by chest X-Ray . Neck should be in neutral position,neither extended nor flexed whild doing the chest X-Ray.

On the other hand,if percussion note is hyper-resonant and breath sound is diminished,suspect Pneumothorax.

DR.DEV KUMAR JHA,MBBS(GOLD MEDALIST),M.D.(PEDIATRICS),FELLOWSHIP IN PEDIATRIC PULMONOLOGY,AIIMS,NEW DELHI