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Speck KE, Kulaylat AN, Baerg JE, Acker SN, Baird R, Beres AL, Chang H, Derderian SC, Englum B, Gonzalez KW, Kawaguchi A, Kelley-Quon L, Levene TL, Rentea RM, Rialon KL, Ricca R, Somme S, Wakeman D, Yousef Y, St Peter SD, Lucas DJ. Evaluation and Management of Primary Spontaneous Pneumothorax in Adolescents and Young Adults: A Systematic Review From the APSA Outcomes & Evidence-Based Practice Committee. J Pediatr Surg 2023; 58:1873-1885. [PMID: 37130765 DOI: 10.1016/j.jpedsurg.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/15/2023] [Accepted: 03/31/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee performed a systematic review of the literature to develop evidence-based recommendations. METHODS Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL, Elsevier Scopus, and Wiley Cochrane Central Register of Controlled Trials databases were queried for literature related to spontaneous pneumothorax between January 1, 1990, and December 31, 2020, addressing (1) initial management, (2) advanced imaging, (3) timing of surgery, (4) operative technique, (5) management of contralateral side, and (6) management of recurrence. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed. RESULTS Seventy-nine manuscripts were included. Initial management of adolescent and young adult primary spontaneous pneumothorax should be guided by symptoms and can include observation, aspiration, or tube thoracostomy. There is no evidence of benefit for cross-sectional imaging. Patients with ongoing air leak may benefit from early operative intervention within 24-48 h. A video-assisted thoracoscopic surgery (VATS) approach with stapled blebectomy and pleural procedure should be considered. There is no evidence to support prophylactic management of the contralateral side. Recurrence after VATS can be treated with repeat VATS with intensification of pleural treatment. CONCLUSIONS The management of adolescent and young adult primary spontaneous pneumothorax is varied. Best practices exist to optimize some aspects of care. Further prospective studies are needed to better determine optimal timing of operative intervention, the most effective operation, and management of recurrence after observation, tube thoracostomy, or operative intervention. LEVEL OF EVIDENCE Level 4. TYPE OF STUDY Systematic Review of Level 1-4 studies.
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Affiliation(s)
- K Elizabeth Speck
- Mott Children's Hospital, University of Michigan, Division of Pediatric Surgery, Ann Arbor, MI, USA.
| | - Afif N Kulaylat
- Penn State Children's Hospital, Division of Pediatric Surgery, Hershey, PA, USA
| | - Joanne E Baerg
- Presbyterian Health Services, Division of Pediatric Surgery, Albuquerque, NM, USA
| | | | - Robert Baird
- British Columbia Children's Hospital, Vancouver, Canada
| | - Alana L Beres
- St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Henry Chang
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | | | - Brian Englum
- University of Maryland Children's Hospital, Baltimore, MD, USA
| | | | | | | | | | - Rebecca M Rentea
- Children's Mercy-Kansas City, Department of Surgery, Kansas City, MO, USA
| | | | - Robert Ricca
- University of South Carolina, Greenville, SC, USA
| | - Stig Somme
- Children's Hospital Colorado, Aurora, CO, USA
| | | | - Yasmine Yousef
- Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Shawn D St Peter
- Children's Mercy-Kansas City, Department of Surgery, Kansas City, MO, USA
| | - Donald J Lucas
- Division of Pediatric Surgery, Naval Medical Center San Diego, CA, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Miscia ME, Castellano M, Chiarini S, Lauriti G, Casaccia M, Lelli Chiesa P, Lisi G. Pediatric primary spontaneous pneumothorax: a comparison of treatment at pediatric surgery vs. thoracic surgery departments. LA PEDIATRIA MEDICA E CHIRURGICA 2023; 45. [PMID: 36920181 DOI: 10.4081/pmc.2023.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/13/2023] [Indexed: 03/16/2023] Open
Abstract
Management of pediatric Primary Spontaneous Pneumothorax (PSP) is controversial and based on guidelines on adults. Therapeutic strategies include: observation, needle aspiration, chest drain, or surgery. We aimed to assess: i) differences in the management of PSP in pediatric vs. adult departments; ii) risk of recurrence associated to each therapeutic choice; iii) management of "large" pneumothorax (i.e. >3cm at the apex on chest X-Ray); iv) role of CT scan in addressing the treatment. We reviewed all PSP treated at Pediatric Surgery Unit (PSU) and Thoracic Surgery Unit for adults (TSU) in a 10-year period (2011 to 2020). We included a total of 42 PSP: 30/42 1st episodes and 12/42 recurrences. Among the 30/42 1st episodes, 15/30 were managed in the PSU and 15/30 in the TSU. Observation was significantly most common among PSU patients (9/15, 60%) vs. TSU cases (1/15, 6.7%; p=0.005]. Chest drain placement was reduced in PSU (3/15, 20%) vs. TSU (12/15, 80%; p=0.002). Observational was associated with a reduced risk of recurrence (0/10, 0%) compared to chest drain (7/15, 46.7%; p=0.01). Management of 20/42 "large" pneumothorax was: 4/20 (20%) observation, 10/20 (50%) chest drain, 2/20 (10%) needle aspiration, 4/20 (20%) surgery. Twentythree/ 29 PSP (79.3%) underwent CT-scan after the first episode. Bullae were detected in 17/23 patients and 5/17 (29.4%) had seven episodes of recurrence. PSP patients treated by PSU were more likely to receive clinical observation. Those managed by TSU were mostly treated by chest drain. Observation seems an effective choice for clinically stable PSP, with low risk of recurrence at a mid-term follow-up. CT-scan seems not to detect those patients at higher risk of recurrence.
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Affiliation(s)
- Maria Enrica Miscia
- Department of Medicine and Aging Science, "G. d'Annunzio" University of Chieti-Pescara, Italy; Pediatric Surgery Unit, "Spirito Santo" Hospital of Pescara.
| | - Maria Castellano
- Department of Medicine and Aging Science, "G. d'Annunzio" University of Chieti-Pescara, Italy; Pediatric Surgery Unit, "Spirito Santo" Hospital of Pescara.
| | | | - Giuseppe Lauriti
- Department of Medicine and Aging Science, "G. d'Annunzio" University of Chieti-Pescara, Italy; Pediatric Surgery Unit, "Spirito Santo" Hospital of Pescara.
| | - Marco Casaccia
- Thoracic Surgery Unit, "Santo Spirito" Hospital of Pescara.
| | - Pierluigi Lelli Chiesa
- Department of Medicine and Aging Science, "G. d'Annunzio" University of Chieti-Pescara, Italy; Pediatric Surgery Unit, "Spirito Santo" Hospital of Pescara.
| | - Gabriele Lisi
- Department of Medicine and Aging Science, "G. d'Annunzio" University of Chieti-Pescara, Italy; 2 Pediatric Surgery Unit, "Santo Spirito" Hospital of Pescara.
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Lieu N, Ngo P, Chennapragada SM, Fitzgerald DA, Karpelowsky J, Pandit C, Selvadurai H, Robinson PD. Update in management of paediatric primary spontaneous pneumothorax. Paediatr Respir Rev 2022; 41:73-79. [PMID: 34511373 DOI: 10.1016/j.prrv.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 11/26/2022]
Abstract
Paediatric spontaneous pneumothorax (PSP) management continues to lack paediatric-specific guideline recommendations. There have been increasing reports of paediatric retrospective case studies supplemented by important well designed RCT (predominantly) adult studies. Taken together, these suggest that conservative management may have an increasing role to play in the management of PSP and that aspiration may have limited utility as a first line intervention. Our local experience, as part of a multicentre retrospective analysis and subsequent audit of management since, corroborates recent published data: it highlights an increasing trend towards conservative management in spontaneous pneumothorax with similar rates of recurrence, compared to intervention, and low use of aspiration with similarly low success rates. We have therefore updated our local practice guidelines and share these with readers. Specifically, we have removed aspiration in the management of primary spontaneous pneumothorax and reserved intervention for children who are clinically unstable or show evidence of increasing air leak irrespective of pneumothorax size. Whilst the success of this change in clinical practice will need to be reviewed in the next 5-10 years, the overall low incidence of the condition, demands a multicentre, and probably multinational, collaborative approach to allow the best chance of obtaining definitive evidence to guide clinical paediatric management.
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Affiliation(s)
- Nathan Lieu
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, New South Wales, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia
| | - Peter Ngo
- Emergency Department, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - S Murthy Chennapragada
- Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia; Department of Interventional Radiology, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, New South Wales, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jonathan Karpelowsky
- Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia; Department of Paediatric Surgery, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Chetan Pandit
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Hiran Selvadurai
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, New South Wales, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia
| | - Paul D Robinson
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, New South Wales, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia.
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Spezzotto G, Boscarelli A, Giangreco M, Ceschiutti G, Codrich D, Scarpa MG, Iaquinto M, Olenik D, Guida E, Schleef J. Management of Primary Spontaneous Pneumothorax in a Third-Level Pediatric Surgical Center: A Retrospective Study. Front Pediatr 2022; 10:945641. [PMID: 35832585 PMCID: PMC9271819 DOI: 10.3389/fped.2022.945641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/02/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The management of primary spontaneous pneumothorax (PSP) in pediatrics remains controversial. The aim of this study was to investigate the risk of recurrence after non-surgical treatment vs. surgery, the difference in the length of stay (LOS) between various treatment options, and the role of computed tomography (CT) in the management of PSP. MATERIALS AND METHODS We retrospectively reviewed patients admitted to our Pediatric Surgery Unit for an episode of PSP between June 2009 and July 2020. Medical records including clinical presentation at admission, diagnostics, treatments, complications, and LOS were collected. RESULTS Twenty-three patients (22 males and 1 female) were included in this study. Median age was 15.65 (range 9-18). Chest X-rays were performed in all patients and showed 5 small (22%) and 18 large (78%) PSP. Chest drain was used for large PSP (≥2 cm) if the patient was clinically unstable. Eleven patients (48%) were managed non-operatively with observation alone and a recurrence rate of 18%, chest drain was used in 11 patients with a recurrence rate of 36%, and surgery was deemed necessary as a first treatment choice in one case. Six patients (27%) had an episode of relapse after non-operative management or chest drain placement. Following surgery, a relapse occurred in 2 of the 6 patients. Chest drain insertion was associated with a longer LOS than observation alone (6.36 vs. 2.4 days), and surgery resulted in a longer LOS than other types of treatment (P = 0.001). CONCLUSION According to our experience, small PSP or clinically stable larger PSP can be treated conservatively with observation alone. Operative management should be taken into consideration in children with large symptomatic PSP, persistent air leak, and/or relapse after chest drain insertion.
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Affiliation(s)
| | - Alessandro Boscarelli
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Manuela Giangreco
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Giulia Ceschiutti
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Daniela Codrich
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Maria-Grazia Scarpa
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Marianna Iaquinto
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Damiana Olenik
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Edoardo Guida
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Jürgen Schleef
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy.,Surgical Department, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
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Namwaing P, Chaisuksant S, Sawadpanich R, Anukunananchai T, Timinkul A, Sakaew W, Sawunyavisuth B, Sukeepaisarnjaroen W, Khamsai S, Sawanyawisuth K. Oxygen saturation associated with recurrent primary spontaneous pneumothorax treated with an intercostal chest drainage. Asian J Surg 2021; 45:431-434. [PMID: 34312054 DOI: 10.1016/j.asjsur.2021.07.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/12/2021] [Accepted: 07/16/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Primary spontaneous pneumothorax (PSP) is a condition that may lead to acute chest pain or dyspnea on exertion. Treatment with an intercostal chest drainage (ICD) is warranted. There is limited data on risk factors of recurrent PSP in patients treated with the ICD alone. This study aimed to evaluate risk factors of recurrent PSP in patients with PSP and treated with the ICD. METHODS This was a retrospective study and enrolled patients diagnosed as PSP and treated with an ICD. Eligible patients were divided into two groups by evidence of recurrent PSP. Baseline characteristics, physical signs, laboratory results, and duration of ICD treatment were studied and recorded from medical charts. Factors associated with recurrent PSP were computed by using multivariate logistic regression analysis. RESULTS There were 80 patients met the study criteria. Of those, 21 patients (26.3%) had recurrent PSP. Of those, 21 patients (26.3%) had recurrent PSP. There were eight factors in the final model for recurrent PSP. Only oxygen saturation at the time of diagnosis was independently associated with recurrent PSP. The adjusted odds ratio (95% confident interval) was 0.57 (0.34, 0.96). A cut point of 96% of oxygen saturation gave sensitivity of recurrent PSP of 80.95%. CONCLUSION The prevalence of recurrent PSP was 26.3% in patients with PSP and treated with the ICD. Initial oxygen saturation may be an indicator for recurrent PSP.
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Affiliation(s)
- Puthachad Namwaing
- Khon Kaen Hospital, Khon Kaen, Thailand; Exercise and Sport Sciences Program, Graduate School, Khon Kaen University, Khon Kaen, Thailand
| | | | | | | | - Akkaranee Timinkul
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Waraporn Sakaew
- Department of Anatomy, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Bundit Sawunyavisuth
- Department of Marketing, Faculty of Business Administration and Accountancy, Khon Kaen University, Khon Kaen, Thailand
| | | | - Sittichai Khamsai
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
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