You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


Background {#Sec1}
==========

Persistent interstitial pulmonary emphysema (PIE) is a rare disease. Very few cases have been reported in premature newborns without invasive mechanical ventilation, and it is even more uncommon in full-term infants, like our patient. When conservative management is not successful, surgical treatment should be considered. In our case, due to clinical instability after a cardiac arrest, we decided to initiate ECMO support and to keep the patient ventilated in order to allow the lung to heal using lung protection strategies. There are no reports on the use of ECMO in patients with PIE even though its efficacy was described a long time ago.

Case presentation {#Sec2}
=================

An 18-day-old male infant with no risk factors was admitted to our hospital due to bronchiolitis caused by Respiratory Sincitial Virus. The initial X-ray showed upper right lobe atelectasis. He received high flow oxygen therapy for 5 days (maximum 10 lpm and FiO2 80 %), but he developed progressive respiratory insufficiency, without signs of bacterial infection. He was admitted to the PICU and required intubation and mechanical ventilation. Chest X-ray at this moment showed unilateral hyperinflation with cystic images (Fig. [1a](#Fig1){ref-type="fig"}). He presented progressive hypoventilation with severe hypercapnia (maximum PaCO~2~ 102 mmHg) and air trapping with autoPEEP of 10 mmHg. He required mechanical ventilation with high pressures (40 mmHg), despite several pulmonary protective strategies: mechanical ventilation with low volumes and long expiratory time, high frequency oscillatory ventilation (HFOV) with maximum settings (Mean airway pressure 15 mmHg, Frequency 8 Hz, Amplitude 45 cmH2O), heliox administration, inhaled nitric oxide, lateral position and selective tracheal intubation.Fig. 1Chest X-Rays showing left lung hyperinflation with cystic images on the day of intubation **a** and a marked improvement after 5 days of ECMO support **b**

The differential diagnosis was made with other cystic lesions such as congenital cystic malformations, cystic lymphangioma and congenital lobar emphysema. Chest computed tomographic scan (CT scan) revealed a severely hyperinflated left lung with extensive destructive changes and multiple small bullae. The left lung was markedly herniated to the right with partial collapse of the right lung and marked deviation of the mediastinum and heart to the right (Fig. [2](#Fig2){ref-type="fig"}). These findings were consistent with diffuse interstitial emphysema (PIE). The patient didn't show clinical or analytical signs of infection and blood and respiratory cultures were negative. For this reason, the possibility of a necrotizing pneumonia due to a bacterial infection was ruled out. Echocardiographic study was normal.Fig. 2Severely hyperinflated left lung with extensive destructive changes and multiple small bullae

He required inotropic support (dopamine, milrinone, adrenaline and noradrenaline) and continuous renal replacement therapy due to hemodynamic instability and acute kidney injury. On the 17^th^ day after admission he suffered a cardiac arrest that required cardiopulmonary resuscitation. After return of spontaneous circulation, we decided to start veno-arterial Extracorporeal Membrane Oxigenation (ECMO) support, through cervical cannulation. It was maintained during 5 days while he was ventilated with very low pressures. The patient showed progressive improvement in ventilation and oxygenation parameters and X-ray images (Fig. [1b](#Fig1){ref-type="fig"}). He was extubated 2 days after the removal of ECMO assistance, after 23 days of mechanical ventilation. One month later, the patient was finally discharged without any supplemental oxygen and the chest X-ray returned to normal. He presented a good neurologic and respiratory evolution. One year later, the neurologic exploration and cerebral magnetic nuclear resonance were normal.

Persistent interstitial pulmonary emphysema (PIE) is a rare disease that is usually seen in preterm infants with mechanical ventilation. The perivascular connective tissue in preterm infants is more abundant and less dissective and air can be trapped in the perivascular space. Other risk factors are surfactant deficiency syndrome, meconium aspiration syndrome and infection \[[@CR1]\].

There are only a few reported cases of PIE developing in premature newborns without invasive mechanical ventilation \[[@CR1]\]. Although it is not common, it has also been reported in full-term infants. In our patient, PIE initiated during HFO therapy but got worse with mechanical ventilation, probably due to the high pressures that were needed to ventilate the patient.

PIE has been described as acute or persistent and local or diffuse. Our patient presented diffuse emphysema because there were smaller cyst in all the lobes of the left lung, and it was persistent in the time. The mechanism of production of PIE is the disruption of the alveolar wall basement membrane with subsequent dissection of air into the interstitial space \[[@CR2]\].

The definitive diagnosis typically requires chest computed tomography. Differential diagnosis must be made with some congenital and acquired diseases as congenital pulmonary airway malformation, bronchogenic cyst, congenital lobar emphysema, lympahngiectasia, cystic lymphangioma and sequelae to infection \[[@CR1], [@CR2]\].

Conservative management includes lateral decubitus positioning and selective bronchial intubation. High frequency oscillatory ventilation and neurally adjusted ventilator assist (NAVA) ventilation can also be useful \[[@CR3]--[@CR5]\].

When there is not spontaneous regression or the patient is unstable, surgical treatment should be considered (i.e. lobectomy in located forms) \[[@CR2]\]. We evaluated this possibility, but given the extent of the lung injury the only feasible option was to perform a pneumonectomy. Because of the consequences to perform a pneumonectomy and the clinical instability of the patient after a cardiac arrest, we decided to initiate ECMO support and to keep patient ventilated and allow the lung to heal using lung protection strategies during the assistance. There are no actually reports on the use of ECMO in patients with PIE even though its efficacy was described a long time ago \[[@CR6]\].

Conclusions {#Sec3}
===========

In summary, we report a 18-day-old male infant with bronchiolitis and PIE associated with mechanical ventilation with high pressures. This disease should be considered in patients with cystic pulmonary lesions and a CT scan should be performed to rule out other congenital or acquired lung diseases. Even though it can be resolved with conservative strategies, sometimes surgical treatment is required, and in our experience, ECMO support could be an option in severe cases.

CARE

:   Guidelines/methodology has been adhered

CPAP

:   Continuous positive airway pressure

CT

:   Computed tomographic

ECMO

:   Extracorporeal Membrane Oxigenation

HFOV

:   High frequency oscillatory ventilation

PIE

:   Persistent interstitial emphysema

We would like to thank Angel Carrillo who contributed by making substantial contributions to interpretation of data of this case.

Funding {#FPar1}
=======

No funding was obtained for this study.

Availability of data and materials {#FPar2}
==================================

All data are contained within the manuscript.

Authors' contributions {#FPar3}
======================

Acquisition of Data: BT, ER, SF, JL. Analysis and Interpretation of Data: BT, IG, RG, JU. Drafting the manuscript: BT, MS. Revisions for intellectual content: BT, JLH. All authors read and approved the final manuscript.

Competing interests {#FPar4}
===================

The authors declare that they have no competing interests.

Consent for publication {#FPar5}
=======================

Written informed consent was obtained from the patient's parents for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.

Ethics approval and consent to participate {#FPar6}
==========================================

Not Applicable for this case report.