Neonatal pneumopericardium (PPC) is a frequently encountered complication of ventilator therapy. However, the appropriate management remains controversial. We describe seven infants who demonstrate the clinical spectrum of PPC. It is apparent that PPC can occur as an asymptomatic finding and may not require invasive therapy. PPC may present also with cardiac tamponade and require immediate diagnosis and therapy. Simple needle pericardiocentesis is appropriate therapy for most cases with tamponade, however a few babies with PPC uncontrolled by needle aspiration required placement of pericardial catheter for continuous drainage of the air. Mortality from PPC with tamponade (86% without therapy) should be much improved with modern management.