Is spontaneous pneumothorax really a pediatric problem? A national perspective

Methods of measurement for pneumothorax in pediatric patients: a systematic review

Accurate measurement of pneumothorax (PTX) size is necessary to guide clinical decision making; however, there is no consensus as to which method should be used in pediatric patients. This systematic review seeks to identify and evaluate the methods used to measure PTX size with CXR in pediatric patients. A systematic review of the literature through 2021 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was conducted using the following databases: Ovid/MEDLINE, Scopus, Cochrane Database of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Original research articles that included pediatric patients (< 18 years old) and outlined the PTX measurement method were included. 45 studies were identified and grouped by method (Kircher and Swartzel, Rhea, Light, Collins, Other) and societal guideline used. The most used method was Collins (n = 16; 35.6%). Only four (8.9%) studies compared validated methods. All found the Collins method to be accurate. Seven (15.6%) studies used a standard classification guideline and 3 (6.7%) compared guidelines and found significant disagreement between them. Pediatric-specific measurement guidelines for PTX are needed to establish consistency and uniformity in both research and clinical practice. Until there is a better method, the Collins method is preferred.

Evaluation and Management of Primary Spontaneous Pneumothorax in Adolescents and Young Adults: A Systematic Review From the APSA Outcomes & Evidence-Based Practice Committee

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.

Thoracoscopic treatment of primary spontaneous pneumothorax without a drainage tube in male patients

OBJECTIVE

To propose a treatment approach for primary spontaneous pneumothorax (PSP) in male patients with a smaller incision and less pain.

METHODS

We retrospectively studied 29 patients with PSP who underwent areola-port video-assisted thoracoscopic surgery (VATS) and 21 patients who underwent single-port VATS. The areola-port VATS technique was performed as follows. First, an arc incision was made along the lower edge of the areola, and a 5-mm-diameter thoracoscope was placed. The bullae were completely removed, and the absence of air leaks and other bullae was confirmed. A drainage tube was placed in the chest with negative pressure and then quickly pulled out, and the reserved suture line was knotted.

RESULTS

All patients were male, and their mean age was 19.07 ± 2.43 years. The mean intraoperative hemorrhage volume and postoperative pain score were significantly lower in the areola-port than single-port group. The mean operative time and mean postoperative hospital stay were also shorter in the areola-port group, but without statistical significance. The incidence of complications and the 1-year postoperative recurrence rate were 0% in both groups.

CONCLUSION

Our method is clinically feasible and inexpensive, has a traceless effect, and is especially suitable for adolescents.

Analysis of Pulmonary Surgery in Children and Adolescents in Germany: Who Is doing What?

INTRODUCTION

 In Germany, pediatric surgery is organized in a decentralized manner. A nationwide clinical registry does not exist. The aim of this research is to analyze the current status of pulmonary surgery in the country in respect of children and adolescents.

MATERIALS AND METHODS

 Claims data have been extracted from two health insurance databases representing 34% of the German population. Operative diagnoses and procedures, as well as patients' characteristics, were recorded from 2016 to 2019.

RESULTS

 The incidence of the four index diagnoses investigated matched the current literature in three of four entities. The main indications <8 years were congenital lung malformations (61%) and spontaneous pneumothorax at age 8 to 17 years (77%). Furthermore, 1,668 pediatric pulmonary procedures (0-17 years) were identified (668 pulmonary resections). Two age peaks were identified: 13% of patients were operated on before 1 year old and 50% of patients were between 15 and 17 years old. Video-assisted-thoracoscopic-surgery (VATS) for pulmonary resections was applied in 62% of cases. 96% of pulmonary resections in patients <1 year and 70% of pulmonary resections in children between 1 and 14 years were performed by pediatric surgeons. Of patients between 15 and 17 years old, only 14% were operated on in pediatric surgery. The estimated average pulmonary resection caseload was 3.2 cases per year and per institution for pediatric surgery and 1.5 for adult surgery.

CONCLUSION

 Indications for pulmonary surgery in children arise from rare diagnoses. In total, 66% of lung resections are performed in patients <1 year and >14 years. The majority of lung resections are performed as VATS. Patients ≤14 years are predominantly operated on by pediatric surgeons. The accessibility of pediatric pulmonary surgery is acceptable, but there is a low caseload per center.

Pneumothorax After a Fall in a Healthy Adolescent Athlete

A pneumothorax is a pathological collection of air in the pleural space within the thoracic cavity. Pneumothoraxes are classified by the underlying etiology as spontaneous or traumatic, with spontaneous pneumothoraxes being further categorized into primary and secondary causes. Management historically involved admission with possible administration of oxygen or chest tube placements based on severity. We herein describe a pediatric ­case of a likely blunt-force traumatic pneumothorax after a fall, successfully managed conservatively in the outpatient setting. The case highlights an acceleration-deceleration blunt trauma caused during a tackle at a football game and the importance of the clinical presentation, physical exam, and confirmation with a chest X-ray.

Children with large primary spontaneous pneumothoraxes may benefit from early operative intervention

PURPOSE

The initial management of primary spontaneous pneumothoraxes (PSP) in children remains controversial, particularly regarding the timing of operative intervention. This study aimed to identify factors associated with failure of non-operative management of PSP.

METHODS

A single-center, retrospective review was performed for patients presenting with PSP. Demographics and clinical predictors were collected. Patients successfully managed non-operatively were compared to failed non-operative management. Fischer exact and Mann-Whitney tests were used as appropriate.

RESULTS

Fifty-seven pediatric patients were identified as having PSP. Four patients underwent initial surgical intervention, 60% (n = 34) were successfully managed non-operatively, while 33% (n = 19) failed non-operative management and underwent video-assisted thoracic surgery (VATS). Those who failed were more likely to have PSP > 2 cm on initial X-ray (79% vs. 44%, p = 0.021) and have a persistent air leak for > 48 h (47% vs 6%, p ≤ 0.001). LOS was greater in the failure group (11.5 ± 5.1 vs 3.1 ± 2.5, p ≤ 0.001) as well as higher complication rates (21% vs 0%, p = 0.013).

CONCLUSION

Our findings suggest that patients presenting with PSP of > 2 cm or have a persistent air leak for > 48 h despite chest tube management are unlikely to be treated by chest tube alone and may benefit from earlier operative intervention.

Pediatric pneumothorax: Case studies and review of current literature

Pneumothorax is an abnormal collection of air between the lung and chest wall. Pneumothorax management guidelines put forth by the American College of Chest Physicians, European Respiratory Society, and British Thoracic Society are specific to adult patients. These guidelines' utility has not been addressed in pediatric populations, which causes significant management variation in younger patients. Additionally, pneumothorax management ranges from conservative to surgical treatment, but these approaches, timelines, and effectiveness have not been validated in significant numbers of pediatric patients. Here, we present three cases of pediatric pneumothorax with variable clinical courses—one with persistent air leak despite chest tube presence who underwent VATS and surgical resection of apical blebs. In contrast, the other two cases were managed more conservatively. We reviewed the current literature for diagnostic and management of pediatric patients with pneumothorax, which underscores the need for guidelines specific to this population.

An evidence-based review of primary spontaneous pneumothorax in the adolescent population

Primary spontaneous pneumothorax (PSP) is a relatively common problem in emergency medicine. The incidence of PSP peaks in adolescence and is most common in tall, thin males. Recent advances in the care of patients with PSP have called into question traditional approaches to management. This clinical review highlights the changing management strategies for PSP and concludes with a proposed evidence-based pathway to guide the care of adolescents with PSP.

High-Resolution CT Following Primary Spontaneous Pneumothorax in Adolescents: Useful Tool or Wasted Radiation?

Background The current trend in management of first-time primary spontaneous pneumothorax (PSP) in children is to obtain a high-resolution chest computerized tomography (HRCT) scan to look for bleb/bullae disease or other forms of structural lung disease. We aimed to evaluate the significance of HRCT findings in relation to initial management strategies, and we hypothesized that these findings do not guide management.  Methods We evaluated patients with first-time PSP in a single-institution, retrospective, longitudinal study. Data were obtained through direct chart review. The primary endpoint was the percentage of patients who underwent surgical intervention after HRCT. Results We identified 10 children from 10 to 17 years old from January 2013 to November 2019 who met criteria for the study. Seven out of 10 patients (70%) had HRCT after the first-time PSP during the same hospital stay. Blebs/bullae were discovered in five out of seven (71%) of those patients. Two of those five patients had subsequent surgical intervention (40%) before a recurrence. Of the three patients with blebs/bullae identified on HRCT treated without initial surgery, two had a recurrence of PSP and subsequently underwent VATS with blebectomy and pleurodesis. Among the patients without initial HRCT, there were no recurrent cases of PSP noted. Conclusions Our study suggests there is value in obtaining HRCT after the first time PSP, as these results can be used to guide management strategies. Further studies in pediatric PSP are needed to validate the sensitivity of HRCT in bleb detection, the predictive value of bleb disease and recurrence, and the benefits and risks of early surgical intervention.

Primary Spontaneous Pneumothorax in Typhoid

We report a rare case of a 12-year-old girl who presented with a short history of diarrhea, vomiting and fever after traveling to Pakistan. During the course of initial investigations, her chest radiograph showed a primary spontaneous pneumothorax. There was no previous history of pulmonary disease. She was diagnosed as having Salmonella Typhi based on positive blood cultures. In the literature, spontaneous pneumothorax has been associated with typhoid fever as a complication of the disease in the pre-antibiotic era. However, a spontaneous pneumothorax associated with typhoid fever has never been reported to our knowledge in the post-antibiotic era.

Metachronous recurrent pediatric primary spontaneous pneumothorax: A case presentation and literature review

•

Pediatric spontaneous pneumothorax is relatively a rare condition.

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A metachronous pneumothorax whether ipsilateral or contralateral side is even rarer.

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Current literature is deficient in a solid consensus for management of this type of pneumothorax.

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Video-assisted thoracoscopic surgery is an excellent therapeutic tool for pediatric pneumothorax.

Introduction

Pediatric primary spontaneous pneumothorax (PSP) is defined as the presence of air in the pleural cavity without underlying lung disease or thoracic trauma. Metachronous recurrence of PSP whether ipsilateral or contralateral is rare. Apical bullae and sub-pleural blebs are found in the majority of PSP patients. As in adults, surgery is indicated in cases with prolonged air leak. Video-assisted thoracoscopic surgery (VATS) is increasingly performed in children and has been reported to be both safe and effective.

Presentation of the case

An 11-years-old girl had bilateral attacks of PSP, the second attack happened one after the first one and this later was associated with her menarche. Chest CT scan detected bilateral apical blebs.

Discussion

Contralateral recurrence in pediatric PSP is a low probability. The decision for surgery in the pediatric age group is a matter of controversy as there are no strict pediatric guidelines for management of PSP. Currently, VATS is superior to open surgery. Pediatric Catamenial pneumothorax is not well described in the literature.

Conclusions

Contralateral recurrence of PSP in children is rarer. No guidelines exist for the management of these cases. The association of pediatric PSP with menarche is not well described in the current literature.

Pleural effusions and pneumothorax: Beyond simple plumbing: Expert opinions on knowledge gaps and essential next steps

Pleural diseases affect millions of people worldwide. Pleural infection, malignant pleural diseases and pneumothorax are common clinical challenges. A large number of recent clinical trials have provided an evidence-based platform to evaluate conventional and novel methods to drain pleural effusions/air which reduce morbidity and unnecessary interventions. These successes have generated significant enthusiasm and raised the profile of pleural medicine as a new subspecialty. The ultimate goal of pleural research is to prevent/stop development of pleural effusions/pneumothorax. Current research studies mainly focus on the technical aspects of pleural drainage. Significant knowledge gaps exist in many aspects such as understanding of the pathobiology of the underlying pleural diseases, pharmacokinetics of pleural drug delivery, etc. Answers to these important questions are needed to move the field forward. This article collates opinions of leading experts in the field in highlighting major knowledge gaps in common pleural diseases to provoke thinking beyond pleural drainage. Recognizing the key barriers will help prioritize future research in the quest to ultimately cure (rather than just drain) these pleural conditions.

Correlation between Sternal Slope Angle and Primary Spontaneous Pneumothorax in Young Males, a Propensity Score Match Analysis

It is generally accepted that primary spontaneous pneumothorax (PSP) is found mostly in tall, thin young males. However, the precise etiology of PSP is unclear. We compared some thoracic structural angles of PSPs and controls in young males to determine the predominant factor. CT data of 43 male PSPs (age 21.88 ± 5.30) and 30 controls (age 21.47 ± 5.47) were collected. The angle of thoracic vertebrae slope (∠α), sternal slope angle (∠β), and tracheal-sternal stem angle (∠γ) were measured in the sagittal position. Carina angle (∠δ) was measured in the coronal position. After a propensity score match (PSM) of age and smoking history, the angles were comparatively evaluated. There were significant differences in all four angles between two unmatched groups, while only in three (∠β, ∠γ, and ∠δ) after PSM was performed. The correlation between ∠β and PSP was most significant, and R² was 0.456. The prediction accuracy of ∠β was 81.3%, OR was 1.386, 95% confidence interval was (1.095-1.754). The sternal slope angles in PSPs are greater than controls indicate the sternal slope angle is associates with the development of PSP and it could be a thoracic structural index to predict the risk of PSP occurrence. Clin. Anat. 33:605-609, 2020. © 2019 Wiley Periodicals, Inc.

Thoracoscopic Resection in the Treatment of Spontaneous Pneumothorax

Objectives:

We retrospectively evaluated the patients with primer spontaneous pneumothorax (PSP) who were treated with thoracoscopic resection.

Methods:

We retrospectively collected the data of the patients with a spontaneous pneumothorax who were operated with video-assisted thoracoscopic surgery (VATS) between 2010 and 2016.

Results:

During the study period, 10 patients applied to our hospital with spontaneous pneumothorax. Five children (three boys, two girls) with a mean age of 16.6 (16-17) were selected with VATS. Three of the patients had bleb, one of the patients had Congenital Cystic Adenomatoid Malformation (CCAM) type 2, and the last one had chronic emphysematous tissue on pathological analyses. Post-operative follow-up time was 2.2 (1-4) years without any complication.

Conclusion:

Spontaneous pneumothorax is a disease especially seen in puberty. The main reasons are apical segment bullae formation and blebs. VATS is especially advantageous to reach apical segments and for easy resections. Blebs, CCAM and emphysematous lung tissue may cause spontaneous pneumothorax.

The Evolution of Surgical Management for Children and Young Adults With Spontaneous Pneumothorax

BACKGROUND

Few studies have analyzed pediatric spontaneous pneumothorax (SPTX) nationally. We sought to better define this patient population and explore the evolution of surgical management.

METHODS

Patients (10-20 y old) with an International Classification of Diseases, Ninth Revision diagnosis of SPTX were identified within the Kids' Inpatient Database for the years 2006, 2009, and 2012. Diagnoses and procedures were analyzed by International Classification of Diseases, Ninth Revision codes. National estimates were obtained using case weighting.

RESULTS

There were 11,792 pediatric SPTX hospitalizations, and patients were predominantly male (84.0%), non-Hispanic white (69.0%), with a mean age of 17.2 y (95% confidence interval, 17.2-17.3). Overall, 52.5% underwent tube thoracostomy as the primary intervention, and more than one-third had a major surgical procedure (34.9%). From 2006 to 2012, there was an increase in bleb excisions from 81.1% to 86.9% and an increase in mechanical pleurodesis from 64.2% to 69.0%. There was a significant change from a predominantly open thoracotomy approach in 2006 (76.1%) to a video-assisted thoracoscopic approach in 2012 (89.3%).

CONCLUSIONS

Pediatric admission for SPTX results in tube thoracostomy in more than half of the cases and surgery in approximately one-third of the cases. Surgical intervention has changed to a more minimally invasive approach during the last decade, and counseling to patients and their families should reflect these updated management strategies.

LEVEL OF EVIDENCE

III.

The influence of pleurodesis on the outcome of primary spontaneous pneumothorax in children

BACKGROUND

Primary spontaneous pneumothorax (PSP) has a high rate of recurrence, and pleurodesis has been shown to decrease the rate of recurrence in adult PSP. For pediatric PSP patients, there are only a few case series available and evidence on the benefits of pleurodesis is insufficient. This study aimed to analyze the outcome of pleurodesis among pediatric PSP patients via a nationwide population-based cohort in Taiwan.

METHODS

The hospitalization data from the pediatric intensive care sampling file of the National Health Insurance Research Database from January 1 to December 31, 2010, were retrieved and analyzed. Children aged 0-18 years with a discharge diagnosis of PSP (ICD-9: 512, 512.0, and 512.8) were enrolled in the study. Demographic data, management strategies, and clinical outcomes were recorded and analyzed as well.

RESULTS

A total of 1005 hospitalization cases were identified and divided into the pleurodesis (409 hospitalizations) and nonpleurodesis (596 hospitalizations) groups. In the univariate analysis, thoracoscopic surgery for PSP decreased the incidence of recurrence (hazard ratio [HR], 0.46; 95% CI, 0.32-0.67) and the need for further surgical intervention (HR, 0.29; 95% CI, 0.18-0.47); however, conventional open surgery did not. A lesser incidence of PSP recurrence (HR, 0.53; 95% CI, 0.37-0.78) and fewer subsequent surgical interventions (HR, 0.32; 95% CI, 0.20-0.52) were found in the pleurodesis group in comparison with the nonpleurodesis group. A multivariate Cox regression analysis revealed that pleurodesis was the only significant factor capable of decreasing the incidence of PSP recurrence (HR, 0.57; 95% CI, 0.38-0.86) and the need for further surgical intervention (HR, 0.40; 95% CI, 0.23-0.69).

CONCLUSION

Pleurodesis reduces the rate of recurrence and the need for further surgical intervention in pediatric PSP. It may be considered as the method of choice for the management of PSP in children.

Thoracoscopic Management of Blebs: Resection With/Out Primary Pleurodesis

OBJECTIVES

To review the literature for justification of thoracoscopic management of blebs in children.

METHODS

PubMed database was reviewed for articles in English, Portuguese and Spanish using the key words "thoracoscopy", "bleb" and "child". Data was collected for age, gender, type of surgery performed, operating time, conversions, complications, recurrences, follow-up and mortality.

RESULTS

Eleven studies with total 266 patients were included (27 bilateral cases; n = 293 surgeries). Median age was 15.7 y (range 11-18 y), 225 were male (87.9%) and 31 were female (12.1%) patients. Endo GIA™ was used in 10 cases, Endoloop® in 11 surgeries, unspecified stapler devices in 150 procedures and, in 122 surgeries, instruments were not mentioned. Pleurodesis was performed in 213 (72.7%) cases. There were 5 (1.7%) conversions (adhesions n = 3, bleeding n = 1, camera failure n = 1). Complications were documented in 8 (2.7%): pneumothorax after chest tube removal 4 (drain reinsertion n = 3, reoperation n = 1); prolonged air leak 3, all submitted to che pleurodesis; bleeding requiring reoperation 1. Recurrence occurred in 25 (8.5%): 10 re-operation, 7 conservative management, 2 chemical pleurodesis, 2 chest tube reinsertions and in 4 the management was not specified. The median follow-up was 46.1 mo (range 3 mo-11 y). There were no lethal outcomes.

CONCLUSIONS

Although data is scarce on specific instruments used, pleurodesis is performed in 70% of cases. Irrespective of this, thoracoscopic resection of blebs can be safely offered as it has a low complication and conversion rates and no mortality.

Non-intubated thoracoscopic bullectomy under sedation is safe and comfortable in the perioperative period

Background

Non-intubated thoracoscopic surgery can be performed under sedation using adjuvant regional anesthesia, however, the benefits of non-intubated thoracoscopic surgery under sedation have not yet been completely verified. In this study, we compare the perioperative safety and pain complaints of sedation without intubation in thoracoscopic bullectomy with that of conventional general anesthesia with double-lumen intubation and mechanical ventilation.

Methods

Forty-one patients with primary spontaneous pneumothorax who were scheduled for thoracoscopic bullectomy were enrolled in this study. Twenty-one patients were under sedation anesthesia (SA group) and 20 patients were under general anesthesia (GA group). In SA group, sedation was done with dexmedetomidine (a loading dose of 1 µg/kg for 10 min and then maintained in dosages of 0.3-1 µg/kg/h) and ketamine (2-4 mg/kg/h intraoperatively). Meanwhile, in GA group, induction with propofol and rocuronium, intubation with double lumen endotracheal tube and maintenance with 1.0-2.5% sevoflurane was done. In both groups, thoracoscopic bullectomy was performed in the same manner and all operations were conducted by single surgeon. Time for anesthesia [including emergence time and post-anesthesia care unit (PACU) recovery time] and operation, postoperative pain, sore throat, hoarseness, adverse events (nausea, vomiting, hypotension and bradycardia), dose of rescue analgesic drug used for 24 hours post-operatively and perioperative arterial blood gas analysis were recorded.

Results

The times for anesthesia, operation and emergence were significantly shorter in SA than GA. Incidence of sore throat were significantly lower in SA. The difference of other adverse events in the two groups was not significant.

Conclusions

Our study demonstrated that compared to double-lumen intubation with general anesthesia, non-intubation with sedation for bullectomy for primary spontaneous pneumothorax was safe and efficient to reduce perioperative time.

Use of autologous blood patch for prolonged air leak in spontaneous pneumothoraces in the adolescent population

Instillation of an autologous blood patch for prolonged air leak (PAL) in chest tube system has been studied and determined to be a safe and effective treatment plan for adults. The current recommended treatment guidelines for a PAL in adolescent secondary to a spontaneous pneumothorax are surgical intervention. This paper serves as documentation of two case reports with successful treatment of PALs with autologous blood patch in two adolescent patients.

ED chest radiography for children with asthma exacerbation is infrequently associated with change of management

BACKGROUND

Acute asthma exacerbations (AAE) account for many Pediatric Emergency Department (PED) visits. Chest radiography (CXR) is often performed in these patients to identify practice-changing findings such as pneumonia (PNA). Limited knowledge exists to balance the cost and radiation dose of CXR with expected yield of clinically meaningful information.

OBJECTIVE

To determine in children with AAE with CXR, whether patient characteristics are associated with radiographic PNA; and significant practice change by initiation of antibiotic.

DESIGN/METHODS

Retrospective chart review of AAE patients with CXR performed in a PED in 2014. We examined univariate associations between patient characteristics and PNA on CXR and administration of antibiotic. Multiple logistic regression models then subsequently examined adjusted associations between patient characteristics and both outcomes.

RESULTS

Of 288 patients, 43 (15%) had PNA on CXR and 51 (17.8%) received antibiotics. There were no statistically significant univariate associations between either outcome and age, race, gender, insurance status, mode of PED arrival, fever or hypoxia (all p>0.11). Crackles were associated with antibiotic administration (p=0.03), but not PNA on CXR (p=0.07). Only previous antibiotic use within 7days had both significant univariate associations (p=0.002) and adjusted associations with both PNA on CXR (aOR 3.6) and antibiotic administration (aOR 3.3).

CONCLUSION

CXR infrequently adds valuable information in children with AAE. Patients treated with antibiotic within 7days are more likely to have PNA identified on CXR and receive antibiotics. A larger study is needed to examine potential significance of hypoxia and crackles.

An Age-Stratified Longitudinal Study of Primary Spontaneous Pneumothorax

PURPOSE

The objective of this study was to determine the age-stratified incidence, frequency, and duration of recurrence of primary spontaneous pneumothorax (PSP).

METHODS

This study analyzed the epidemiology of PSP among hospitalized patients using the National Health Research Institutes of Taiwan database. The incidence of PSP was determined from a cohort of 19,562 deidentified individuals with PSP between 2001 and 2013. The insurants consisted of 99% of the Taiwan population of about 23 million people. A 5- to 12-year long-term recurrence analysis was based on data from 11,190 patients with PSP between 2001 and 2008.

RESULTS

The incidence of PSP in in-patients increased from 5.05 to 7.18/100,000 in a 13-year analysis. The age group at highest risk was 15-22 years with incidence rates >11/100,000 and readmission rates of 17%-31%. About 20% of patients had more than one attack based on long-term follow-ups. About .8% of patients had more than three hospital admissions. Only 3.9% of patients had repeated or recurrent attacks after more than 4 years. All patients who had been admitted on more than four occasions were adolescents, except for four patients who were aged between 20 and 24 years old.

CONCLUSIONS

Adolescents with PSP had a higher incidence of attacks and more frequent and longer periods of vulnerability to recurrence. The majority of patients experienced recurrence during the first 4 years after the first attack.

Surgical Intervention for Primary Spontaneous Pneumothorax in Pediatric Population: When and Why?

INTRODUCTION

Spontaneous pneumothorax in pediatric patients is relatively uncommon. The management strategy varies in different centers due to dearth of evidence-based pediatric guidelines. In this study, we reviewed our experience of thoracoscopic management of primary spontaneous pneumothorax (PSP) in children and identified risk factors associated with postoperative air leakage and recurrence.

MATERIALS AND METHODS

We performed a retrospective analysis of pediatric patients who had PSP and underwent surgical management in our institution between April 2008 and March 2015. Demographic data, radiological findings, interventions, and surgical outcomes were analyzed.

RESULTS

A total of 92 patients with 110 thoracoscopic surgery for PSP were identified. The indications for surgery were failed nonoperative management with persistent air leakage in 32.7%, recurrent ipsilateral pneumothorax in 36.4%, first contralateral pneumothorax in 14.5%, bilateral pneumothorax in 10%, and significant hemopneumothorax in 5.5%. Bulla was identified in 101 thoracoscopy (91.8%) with stapled bullectomy performed. 14.5% patients had persistent postoperative air leakage and treated with reinsertion of thoracostomy tube and chemical pleurodesis. 17.3% patients had postoperative recurrence occurred at mean time of 11 months. Operation within 7 days of symptoms onset was associated with less postoperative air leakage (P = .04). Bilateral pneumothorax and those with abnormal radiographic features had significantly more postoperative air leakage (P = .002, P < .01 respectively) and recurrence (P < .01, P = .007).

CONCLUSION

Early thoracoscopic mechanical pleurodesis and stapled bullectomy after thoracostomy tube insertion could be offered as a primary option for management of large PSP in pediatric population, since most of these patients had bulla identified as the culprit of the disease.

Pneumothorax in a young man with anorexia nervosa

Primary spontaneous pneumothorax (PSP) is defined as a pneumothorax that occurs in the absence of an external cause in an individual without underlying generalized lung disease. A number of factors are important and should be carefully considered in the pathogenesis of PSP. This is the first case report of a PSP in a severely malnourished adolescent male with anorexia nervosa (AN) who was involved in excessive physical activity. Clinicians caring for adolescents with AN and vigorous exercise need to be aware of the risk factors associated with the development of a PSP. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:895-898).

Video-assisted thoracoscopic treatment of primary spontaneous pneumothorax in older children and adolescents

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a relatively rare condition in the pediatric population lacking of specific recommendations regarding the management. Video-assisted thoracoscopic surgery (VATS) has gained widespread consensus during the last 10 years. We retrospectively reviewed our experience of VATS in the treatment of pediatric patients affected by PSP in terms of timing of surgery, operative technique, and postoperative outcome.

METHODS

Between 1998 and 2014, 58 pediatric patients were treated for PSP. Treatment consisted in pulmonary apicectomy in all patients and pleurodesis. Patients received either apical pleurectomy and mechanical pleurodesis or mechanical pleurodesis alone.

RESULTS

Mean age was 16.6 ± 1.6 years (range 10-18) with a male/female ratio of 5:1. Seventeen patients underwent surgery after the first episode of PSP. Apical pleurectomy and mechanical pleurodesis was performed in 30 patients while others received mechanical pleurodesis alone. Conversion to open surgery was needed in four procedures (6.9%). Postoperative complications occurred in 1.7% of cases. Sixteen patients received more than one procedure for contralateral pneumothorax (15 cases) and postoperative recurrence (1 case). The mean follow-up was 95 ± 63 months. Recurrence rate was 12.1%. Univariate analysis showed that recurrence was significantly correlated with younger age (P = 0.044) and postoperative chest tube (P = 0.027). Both univariate and multivariate analysis showed that apical pleurectomy did not prevent recurrences.

CONCLUSIONS

VATS is an effective procedure for PSP in pediatric patients. Apical pleurectomy does not seem to prevent recurrence. Due to the increased risk of recurrence of PSP in younger patients, indication to VATS after the first episode might be considered. Pediatr Pulmonol. 2016;51:713-716. © 2016 Wiley Periodicals, Inc.

Spontaneous pneumothorax in children - management, results, and review of the literature

Introduction

Primary spontaneous pneumothorax (PSP) occurs at a frequency of 7.4-18 cases per 100 000 population per year. The PSP typically occurs in young adults and is uncommon in children. The aim of this study was to review our institutional experience with PSP in children.

Material and methods

Twenty-two paediatric patients with confirmed PSP, treated from 2004 to 2014 at the Paediatric Surgery Clinic. There were 18 boys and 4 girls. The mean age was 16 years, 6 months ± 1 month (range 14-17). The mean body mass index (BMI) was 20.1 (ranging from 17 to 24).

Results

The recurrence rate of PSP was 48%. The mean interval of the recurrence was 5 months ± 1 month (range from 3 weeks to 2 years). Recurrent pneumothorax was evacuated by thoracostomy with success in four patients. The first video-assisted thoracoscopic surgery (VATS) procedure had a failure rate of 50%. After second VATS procedure, we did not observe recurrent PSP in two patients. One patient with recurrent PSP, after two VATS procedures, was treated with success, with an open mini axillary thoracotomy. The mean follow-up period was 4 years 3 months ± 1 month (range 6 months – 10 years). We have not noted any intraoperative complications.

Conclusions

Although our study is limited by the small number of patients, we conclude that most patients resolve their spontaneous pneumothorax and air leak with tube thoracostomy alone. For those patients in whom chest tube drainage is not effective, and for those with recurrent PSP, early VATS and bullectomy combined with pleural abrasion is the most efficient intervention.

Management of paediatric spontaneous pneumothorax: a multicentre retrospective case series

OBJECTIVES

Paediatric guidelines are lacking for management of spontaneous pneumothorax. Adult patient-focused guidelines (British Thoracic Society 2003 and 2010) introduced aspiration as first-line intervention for primary spontaneous pneumothorax (PSP) and small secondary spontaneous pneumothoraces (SSP). Paediatric practice is unclear, and evidence for aspiration success rates is urgently required to develop paediatric-specific recommendations.

METHODS

Retrospective analysis of PSP and SSP management at nine paediatric emergency departments across Australia and New Zealand (2003-2010) to compare PSP and SSP management.

RESULTS

219 episodes of spontaneous pneumothorax occurred in 162 children (median age 15 years, 71% male); 155 PSP episodes in 120 children and 64 SSP episodes in 42 children. Intervention in PSP vs SSP episodes occurred in 55% (95% CI 47% to 62%) vs 70% (60% to 79%), p<0.05. An intercostal chest catheter (ICC) was used in 104/219 (47%) episodes. Aspiration was used in more PSP than in SSP episodes with interventions (27% (18% to 37%) vs 9% (3% to 21%), p<0.05). Aspiration success was 52% (33% to 70%) overall and not significantly different between PSP and SSP. Aspiration success was greater in small vs large pneumothoraces (80% (48% to 95%) vs 33% (14% to 61%), p=0.01). Small-bore ICCs were used in 40% of ICCs and usage increased during the study.

CONCLUSIONS

In this descriptive study of pneumothorax management, PSP and SSP management did not differ and ICC insertion was the continuing preferred intervention. Overall success of aspiration was lower than reported results for adults, although success was greater for small than for large pneumothoraces. Paediatric prospective studies are urgently required to determine optimal paediatric interventional management strategies.

Rapid increase in the height and width of the upper chest in adolescents with primary spontaneous pneumothorax

BACKGROUND

We determined the chest height in a cohort of patients with primary spontaneous pneumothorax (PSP) who had received chest radiographic examinations prior to the attack. The aim of this study was to determine when their chest height began to change and how this was related to the PSP.

METHODS

From June 2009 to February 2012, the chest posteroanterior radiographs of 156 patients with PSP (Group 1) were reviewed. Among another 3134 patients with PSP, we identified 52 patients who had a chest posteroanterior radiograph prior to the attack (Group 2). We also recruited 196 controls for comparison (Group 3). The chest height and chest width at different levels were measured and analyzed.

RESULTS

Before 14 years of age, the chest height of patients in Group 2 was no different from that of patients in Group 3. By the age of 14 years, however, the chest height and upper chest width of patients with PSP was significantly higher than that of the normal controls. The difference from normal chest height did not increase at adulthood.

CONCLUSION

The rapid increase in chest height and upper chest width is a unique finding in patients with PSP. It might be attributable to the occurrence of PSP. This finding may also help to identify patients who are at risk of PSP.

Pneumothorax from subpleural blebs-a new association of sotos syndrome?

We describe two unrelated patients with molecularly confirmed Sotos syndrome with multiple subpleural blebs and pneumothorax. We propose this as a new association. Patient 1 is a 3-year-old boy with a 1.9 Mb interstitial deletion of the long arm of chromosome 5, with breakpoints at q35.2 and q35.3, encompassing NSD1 and Patient 2 is a 9-year-old girl with a de novo truncating mutation within NSD1. Both patients presented with sudden onset dyspnea due to a unilateral pneumothorax: Patient 1 at the age of 18 months and Patient 2 at 9 years. In both, the pneumothorax recurred following removal of the chest drain and, on further investigations, multiple subpleural blebs were identified necessitating a pleurodesis and tissue resection. This is the first report of multiple subpleural blebs leading to pneumothorax in association with Sotos syndrome. Given the similar and unusual presentation in the two affected patients, we suggest that this may be a real association, albeit a rare one. While screening would not be advocated for such a rare association, we recommend that clinicians consider pneumothorax in patients with Sotos syndrome and sudden onset of dyspnea and are aware that it may be refractory to first line treatment.