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Eamer G, Povolo CA, Petropoulos JA, Ohinmaa A, Vanhouwelingen L. Observation, Aspiration, or Tube Thoracostomy for Primary Spontaneous Pneumothorax: A Systematic Review, Meta-Analysis, and Cost-Utility Analysis. Chest 2023; 164:1007-1018. [PMID: 37209773 DOI: 10.1016/j.chest.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 04/30/2023] [Accepted: 05/01/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Primary spontaneous pneumothorax (PSP) has several commonly used management strategies: observation, aspiration, and chest tube placement. Economic modelling of pooled data comparing techniques has not been performed. RESEARCH QUESTION Based on studies from the past 20 years, which approach to management of PSP delivers the highest utility? STUDY DESIGN AND METHODS A systematic review of PSP management strategies (observation, aspiration, or chest tube placement) included in the Medline and EMBASE databases from January 1, 2000, through April 10, 2020, was conducted. Text screening, bias assessment, and data extraction were performed by two authors (G. E. and C. A. P.). Inclusion and exclusion criteria were defined a priori. The primary outcome was PSP resolution after the initial intervention. Secondary outcomes were PSP recurrence, length of stay, rate of surgical management, and complications. The meta-analysis compared treatment arms; dichotomous outcomes were reported as relative risk (RRs) and continuous outcomes were reported as mean differences. A cost-utility analysis within the Canadian health care system context with deterministic and probabilistic sensitivity analyses was performed. RESULTS Five thousand one hundred seventy-nine articles were identified; after screening, 22 articles were included. Most trials showed a high risk of bias, but randomized trials showed a lower risk. Compared with chest tube placement, observation (mean difference, 5.17; 95% CI, 3.75-6.59; P < .01; I2 = 62%) and aspiration (mean difference, 2.72; 95% CI, 2.39-3.04; P < .01; I2 = 0%) showed a shorter length of stay. Compared with observation, chest tube placement (RR, 0.81; 95% CI, 0.71-0.91; P < .01; I2 = 62%) and aspiration (RR, 0.73; 95% CI, 0.61-0.88; P < .01; I2 = 67%) showed higher resolution without additional intervention. Two-year recurrence rates did not differ between management strategies. Observation showed the best utility (0.82) and lowest cost; observation was the optimal strategy in 98.2% of Monte Carlo simulations. INTERPRETATION Observation is the dominant choice compared with aspiration and chest tube placement for PSP. It should be considered as the first-line therapy in appropriately selected patients.
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Affiliation(s)
- Gilgamesh Eamer
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada; Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
| | - Christopher A Povolo
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Arto Ohinmaa
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Lisa Vanhouwelingen
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; McMaster Children's Hospital, Hamilton, ON, Canada
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Stewart S, Fraser JA, Rentea RM, Aguayo P, Juang D, Fraser JD, Snyder CL, Hendrickson RJ, Oyetunji TA, St Peter SD. Management of primary spontaneous pneumothorax in children: A single institution protocol analysis. J Pediatr Surg 2023:S0022-3468(23)00075-1. [PMID: 36803908 DOI: 10.1016/j.jpedsurg.2022.12.034] [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: 06/30/2022] [Revised: 12/13/2022] [Accepted: 12/31/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Midwest Pediatric Surgery Consortium (MWPSC) suggested a simple aspiration of primary spontaneous pneumothorax (PSP) protocol, failing which, Video-Assisted Thoracoscopic Surgery (VATS) should be considered. We describe our outcomes using this suggested protocol. METHODS A single institution retrospective analysis was conducted on patients between 12 and 18 years who were diagnosed with PSP from 2016 to 2021. Initial management involved aspiration alone with a ≤12 F percutaneous thoracostomy tube followed by clamping of the tube and chest radiograph at 6 h. Success was defined as ≤2 cm distance between chest wall and lung at the apex and no air leak when the clamp was released. VATS followed if aspiration failed. RESULTS Fifty-nine patients were included. Median age was 16.8 years (IQR 15.9, 17.3). Aspiration was successful in 33% (20), while 66% (39) required VATS. The median LOS with successful aspiration was 20.4 h (IQR 16.8, 34.8), while median LOS after VATS was 3.1 days (IQR 2.6, 4). In comparison, in the MWPSC study, the mean LOS for those managed with a chest tube after failed aspiration was 6.0 days (±5.5). Recurrence after successful aspiration was 45% (n = 9), while recurrence after VATS was 25% (n = 10). Median time to recurrence after successful aspiration was sooner than that of the VATS group [16.6 days (IQR 5.4, 19.2) vs. 389.5 days (IQR 94.1, 907.0) p = 0.01]. CONCLUSION Simple aspiration is safe and effective initial management for children with PSP, although most will require VATS. However, early VATS reduces length of stay and morbidity. LEVEL OF EVIDENCE IV. Retrospective study.
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Affiliation(s)
- Shai Stewart
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - James A Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - David Juang
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Richard J Hendrickson
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.
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Ma L, Yin M, Yang XL, Xu W. Risk factors for air leakage during invasive mechanical ventilation in pediatric intensive care units. Eur J Med Res 2022; 27:218. [DOI: 10.1186/s40001-022-00858-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/16/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Purpose
This study aimed to investigate air leakage during invasive mechanical ventilation (IMV) in a pediatric intensive care unit (PICU) and explore potential risk factors.
Methods
We conducted a retrospective cohort study of children who underwent IMV in a single-center PICU in a tertiary referral hospital. Air leakage risk factors and factors associated with an improved outcome were assessed.
Results
A total of 548 children who underwent IMV were enrolled in this study. Air leakage occurred in 7.5% (41/548) of the cases in the PICU. Air leakage increased the duration of IMV and hospitalization time. Multivariate logistic regression analysis showed a higher risk of air leakage during IMV for PICU patients with acute respiratory dyspnea syndrome (ARDS) (OR = 4.38), a higher pediatric critical illness score (PCIS) (OR = 1.08), or a higher peak inspiratory pressure (PIP) (OR = 1.08), whereas the risk was lower for patients with central respiratory failure (OR = 0.14). The logistic model had excellent predictive power for air leakage, with an area under the curve of 0.883 and tenfold cross-validation. Patients aged between 1 and 6 years who were diagnosed with measles or pneumonia and had a low positive end-expiratory pressure (PEEP) or high PaO2/FiO2 ratio were associated with improved outcomes. Patients diagnosed with central respiratory failure or congenital heart diseases were associated with less desirable outcomes.
Conclusions
Patients with ARDS, a higher PCIS at admission or a higher PIP were at higher risk of air leakage.
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Contemporary Role of Computed Tomography in Managing Pediatric Primary Spontaneous Pneumothorax. J Surg Res 2022; 276:256-260. [PMID: 35398629 DOI: 10.1016/j.jss.2022.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/23/2022] [Accepted: 03/11/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The value of chest computed tomography (CT) in pediatric primary spontaneous pneumothorax (PSP) remains controversial. This study sought to evaluate the utility of CT scans in a contemporary cohort of children with PSP. MATERIALS AND METHODS An institutional review board approval was obtained for a retrospective review of all children (aged ≤18 y) who underwent video-assisted thoracoscopic surgery (VATS) for PSP between 2009 and 2019 at a university-affiliated pediatric hospital. Preoperative CT scans were evaluated for diagnostic accuracy of the CT of bleb disease. RESULTS Thirty nine patients underwent VATS procedures for PSP, 34 (87%) of the patients were noted to have blebs. Twenty eight (72%) patients received preoperative CT scans with a 5.5:1 male to female ratio. On CT, 17 (61%) were diagnosed with blebs and all had blebs intraoperatively. CT did not identify disease in 11 patients, but seven had blebs intraoperatively. The positive and negative predictive values of preoperative CT for detecting ipsilateral bleb disease were 100% and 36%, respectively, with a sensitivity of 71%. Eleven patients had a contralateral disease on CT (39%). Five received elective contralateral VATS and three developed spontaneous PSP, with intraoperative blebs in all eight patients. Three never developed contralateral PSP. Six (21%) patients with no contralateral disease on CT developed spontaneous PSP with intraoperative blebs. CONCLUSIONS The decision to operate for PSP should be made based on clinical findings rather than on the presence or absence of blebs identified by CT.
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Benhaïm E, Roth B, Michel F, Merrot T, Dubus J. Management of primary spontaneous pneumothorax in teenagers: An 11-year study. Acta Paediatr 2022; 111:845-849. [PMID: 34923666 DOI: 10.1111/apa.16223] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/29/2021] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Abstract
AIM Management of teenagers with primary spontaneous pneumothorax (PSP) is not consensual. We report our experience over an 11-year period. METHODS For each patient under 20 years hospitalised with PSP from 2008 to 2018, demographic data, smoking habits, clinical presentation, hospitalisation unit, radiological management and its results, therapeutic management (observation, needle aspiration, chest tube drainage and surgery), complications, length of stay, given advice at discharge and recurrence were collected. RESULTS Seventy patients were included in different paediatric or adult surgery or pulmonology wards (82.9% boys; 16.8 ± 1.7 years; one severe presentation; 18/58 smokers). Chest CT-scan (n = 42/70, 60%) revealed blebs/bullae in 18/39 examinations (46.2%). Treatment consisted of observation (14/70, 20%), needle aspiration (2/70, 2.9%), chest tube (53/70, 75.7%) and video-assisted thoracoscopy surgery (27/70, 38.6%). Half patients with interventional procedure presented complications. A median of 10 chest X-rays was noted during a median stay of 8 days. Advice concerning sport practice, flying, smoking, etc., was variably delivered. PSP recurrence concerned 35/70 patients (50%) without identified predictive factors. CONCLUSION Compared to recent recommendations of a more conservative approach, chest CT-scan and interventional strategy are overused in our teenagers with PSP. Observation, more or less needle aspiration, should be clearly the first-line treatments.
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Affiliation(s)
- Eve Benhaïm
- Unité de Pneumologie Pédiatrique Centre Hospitalo‐Universitaire (CHU) Timone‐Enfants Marseille France
| | - Brimbelle Roth
- Département de Santé Publique Centre Hospitalo‐Universitaire (CHU) de la Conception Marseille France
| | - Fabrice Michel
- Unité d’Anesthésie‐Réanimation Pédiatrique Centre Hospitalo‐Universitaire (CHU) Timone‐Enfants Marseille France
| | - Thierry Merrot
- Département de Chirurgie Viscérale Pédiatrique Centre Hospitalo‐Universitaire (CHU) Timone‐Enfants Marseille France
| | - Jean‐Christophe Dubus
- Unité de Pneumologie Pédiatrique Centre Hospitalo‐Universitaire (CHU) Timone‐Enfants Marseille France
- Aix Marseille Université IRD AP‐HM MEPHI IHU‐Méditerranée Infection Marseille France
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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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Wilson PM, Rymeski B, Xu X, Hardie W. An evidence-based review of primary spontaneous pneumothorax in the adolescent population. J Am Coll Emerg Physicians Open 2021; 2:e12449. [PMID: 34179877 PMCID: PMC8212556 DOI: 10.1002/emp2.12449] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- Paria M. Wilson
- Department of PediatricsUniversity of CincinnatiCollege of MedicineCincinnatiOhioUSA
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Beth Rymeski
- Division of Pediatric SurgeryCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Xuefeng Xu
- Department of RheumatologyImmunology & AllergyRespiratory MedicineThe Children's HospitalZhejiang University School of MedicineNational Clinical Research Center for Child HealthHangzhouChina
| | - William Hardie
- Department of PediatricsUniversity of CincinnatiCollege of MedicineCincinnatiOhioUSA
- Division of Pulmonary MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
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Cerchia E, Conighi ML, Bleve C, Chiarenza SF, Sgrò A, Pini Prato A, Rotundi F, Parolini F, Bulotta AL, Alberti D, Rena O, Rapuzzi G, Rossi F, La Canna F, Cheli M. Feasibility of a Standardized Management for Primary Spontaneous Pneumothorax in Children and Adolescents: A Retrospective Multicenter Study and Review of the Literature. J Laparoendosc Adv Surg Tech A 2020; 30:841-846. [DOI: 10.1089/lap.2019.0493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- Elisa Cerchia
- Department of Pediatric Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | - Cosimo Bleve
- Department of Pediatric Surgery, S. Bortolo Hospital, Vicenza, Italy
| | | | - Alberto Sgrò
- Department of Pediatric Surgey, Alessandria Children Hospital, Alessandria, Italy
| | - Alessio Pini Prato
- Department of Pediatric Surgey, Alessandria Children Hospital, Alessandria, Italy
| | - Franco Rotundi
- Department of Pediatric Surgey, Alessandria Children Hospital, Alessandria, Italy
| | - Filippo Parolini
- Department of Pediatric Surgery, “Spedali Civili” Children's Hospital, Brescia, Italy
| | - Anna Lavinia Bulotta
- Department of Pediatric Surgery, “Spedali Civili” Children's Hospital, Brescia, Italy
| | - Daniele Alberti
- Department of Pediatric Surgery, “Spedali Civili” Children's Hospital, Brescia, Italy
| | - Ottavio Rena
- Department of Pediatric Surgery Unit, AOU “Maggiore della Carità,” Novara, Italy
| | - Giovanni Rapuzzi
- Department of Pediatric Surgery Unit, AOU “Maggiore della Carità,” Novara, Italy
| | - Fabio Rossi
- Department of Pediatric Surgery Unit, AOU “Maggiore della Carità,” Novara, Italy
| | - Francesco La Canna
- Department of Pediatric Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Maurizio Cheli
- Department of Pediatric Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
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Ng GYH, Nah SA, Teoh OH, Ong LY. Primary spontaneous pneumothorax in children: factors predicting recurrence and contralateral occurrence. Pediatr Surg Int 2020; 36:383-389. [PMID: 31993738 DOI: 10.1007/s00383-020-04619-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The risk factors for recurrence in primary spontaneous pneumothorax (PSP) in children are not well known. We aimed to identify possible risk factors, and to evaluate the utility of computerised tomography (CT) scans in predicting future episodes. METHODS We reviewed children aged < 18 years admitted to our institution for PSP from 2008 to 2017, excluding those with malignancies. Basic demographic data were extracted. Clinical data collected include pneumothorax laterality, CT results, treatment protocols and recurrences. RESULTS 63 patients were included, 19 (30.2%) of whom had CT scans. A total of 41 surgeries were performed. The median (interquartile range) age was 15.4 years (14.9-15.9), and body-mass index was 17.9 kg/m2 (15.8-19.3). 56 (88.9%) patients were male. Median follow-up duration was 19.8 months (11.6-35.9). Multivariate logistic regression analyses identified surgery in the first episode as a predictor for a subsequent contralateral occurrence (odds ratio [95% confidence interval] 32.026 [1.685-608.518], p = 0.021). No predictors for ipsilateral recurrence were found. CT scans were 76.5% sensitive for bleb detection, and predicted poorly for occurrence (positive predictive value 14.3%, likelihood ratio 1.1). CONCLUSION This is the first study demonstrating that surgery at first presentation appears to predict for occurrence of PSP on the contralateral lung. CT appears to be ineffective in detecting blebs and predicting PSP occurrence.
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Affiliation(s)
- Glenn Yang Han Ng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,General Paediatrics Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore.,Paediatric Surgery Unit, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Oon Hoe Teoh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Respiratory Medicine Service, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Lin Yin Ong
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore. .,Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore. .,Duke-NUS Medical School, Singapore, Singapore.
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Changing the Paradigm for Management of Pediatric Primary Spontaneous Pneumothorax: A Simple Aspiration Test Predicts Need for Operation. J Pediatr Surg 2020; 55:169-175. [PMID: 31706614 DOI: 10.1016/j.jpedsurg.2019.09.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 09/29/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE Chest tube (CT) management for pediatric primary spontaneous pneumothorax (PSP) is associated with long hospital stays and high recurrence rates. To streamline management, we explored simple aspiration as a test to predict need for surgery. METHODS A multi-institution, prospective pilot study of patients with first presentation for PSP at 9 children's hospitals was performed. Aspiration was performed through a pigtail catheter, followed by 6 h observation with CT clamped. If pneumothorax recurred during observation, the aspiration test failed and subsequent management was per surgeon discretion. RESULTS Thirty-three patients were managed with simple aspiration. Aspiration was successful in 16 of 33 (48%), while 17 (52%) failed the aspiration test and required hospitalization. Twelve who failed aspiration underwent CT management, of which 10 (83%) failed CT management owing to either persistent air leak requiring VATS or subsequent PSP recurrence. Recurrence rate was significantly greater in the group that failed aspiration compared to the group that passed aspiration [10/12 (83%) vs 7/16 (44%), respectively, P=0.028]. CONCLUSION Simple aspiration test upon presentation with PSP predicts chest tube failure with 83% positive predictive value. We recommend changing the PSP management algorithm to include an initial simple aspiration test, and if that fails, proceed directly to VATS. TYPE OF STUDY Prospective pilot study LEVEL OF EVIDENCE: Level III.
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11
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Gariépy M, Beaunoyer M, Miron MC, Gravel J. Management and recurrence of spontaneous pneumothorax in children. Paediatr Child Health 2019; 25:86-92. [PMID: 33390745 DOI: 10.1093/pch/pxz032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/17/2019] [Indexed: 11/12/2022] Open
Abstract
Objective No guideline clearly prescribes an approach to management of spontaneous pneumothorax in children. The objectives of this study were to evaluate practice variation in the management of spontaneous pneumothorax in children and its probability of recurrence. Methods This study was a retrospective chart review followed by a phone follow-up that included all children who had visited a tertiary care paediatric hospital for a first episode of spontaneous pneumothorax between 2008 and 2017. The primary outcomes were the management of pneumothorax (observation, oxygen, needle aspiration, intercostal chest tube, surgery) and the probability of recurrence. All charts were evaluated by a rater using a standardized report form and 10% of the charts were evaluated in duplicate. All children/families were contacted by phone to assess recurrence. The primary analyses were the proportions of each treatment modalities and recurrence, respectively. Results During the study period, 76 children were deemed eligible for the study. Among them, 59 had a primary spontaneous pneumothorax while 17 were secondary. The most common first therapeutic approaches were chest tube insertion (31), oxygen alone (27), and observation (14). A total of 54 patients were available for follow-up among whom a recurrence was observed in 28 (37% of the total cohort or 52% of available children). Conclusion Chest tube insertion was the first line of treatment in about 40% of children with a first spontaneous pneumothorax. In this population, the recurrence probability is established between 37 and 52% and the majority occurs in the following months.
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Affiliation(s)
- Martin Gariépy
- Faculty of Medicine, Université Laval, Quebec City, Quebec
| | - Mona Beaunoyer
- Department of Surgery, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec
| | - Marie-Claude Miron
- Department of Radiology, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec
| | - Jocelyn Gravel
- Department of Pediatrics Emergency Medicine, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec
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Kaslow J, Bickel S, Wiesenauer C, Eid N, Morton R. Pediatric Spontaneous Pneumothorax: Our Experience and a Review of the Literature. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2018. [DOI: 10.1089/ped.2018.0931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Jacob Kaslow
- Division of Allergy, Immunology, and Pulmonary Medicine, Vanderbilt University, Nashville, Tennessee
| | - Scott Bickel
- Division of Pediatric Pulmonology, University of Louisville, Louisville, Kentucky
| | - Chad Wiesenauer
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Nemr Eid
- Division of Pediatric Pulmonology, University of Louisville, Louisville, Kentucky
| | - Ronald Morton
- Division of Pediatric Pulmonology, University of Louisville, Louisville, Kentucky
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13
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Soler LM, Raymond SL, Larson SD, Taylor JA, Islam S. Initial primary spontaneous pneumothorax in children and adolescents: Operate or wait? J Pediatr Surg 2018; 53:1960-1963. [PMID: 29361279 DOI: 10.1016/j.jpedsurg.2017.12.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/14/2017] [Accepted: 12/01/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE The management of primary spontaneous pneumothorax (PSP) in the pediatric population is not standardized. The purpose of this study was to understand the management options for a first episode of PSP in children and adolescents, and their associated outcomes. METHODS A retrospective study was conducted for patients 5-20 years old with a diagnosis of PSP at a large academic children's hospital between 2002 and 2014. Patient data were reviewed for each case. Management and outcomes were analyzed and compared between groups. RESULTS Eighty patients met all inclusion criteria. Overall recurrence rate was 40% with 86% occurring within 12 months of the initial PSP. Patients with recurrent PSP were significantly taller. Size of pneumothorax based on initial chest x-ray was comparable between recurrent and nonrecurrent groups. A negative CT scan for subpleural blebs did not predict recurrence. Patients undergoing thoracoscopic blebectomy and mechanical pleurodesis at initial presentation had significantly lower recurrence rate compared to patients who underwent nonoperative management (operative group 14%, nonoperative group 45%; p=0.0373). CONCLUSIONS Recurrence following nonoperative management was high with the majority occurring within a year and requiring readmission. These findings support offering surgery to families as a potential initial management option. LEVEL OF EVIDENCE 3b/4 - retrospective series or case control study, single institution, very limited population.
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Affiliation(s)
- Lisa M Soler
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Steven L Raymond
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Shawn D Larson
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Janice A Taylor
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Saleem Islam
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.
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14
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Kerr H, Bowen B, Light D. Thoracoabdominal Injuries. CONTEMPORARY PEDIATRIC AND ADOLESCENT SPORTS MEDICINE 2018. [PMCID: PMC7123492 DOI: 10.1007/978-3-319-56188-2_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Trauma to the thorax and abdomen can occur during participation in sports. This chapter reviews some of the more common presentations of such injuries and how such injuries should be best managed. Thoracic injuries reviewed include internal injuries such as pneumothorax, pulmonary contusion, hemothorax, commotio cordis, and cardiac contusion. Chest wall injuries are also reviewed such as rib fractures, costochondritis, and slipping rib syndrome plus sternal and scapular fractures. Abdominal injuries reviewed are focused on internal organ trauma to the spleen and liver, kidney, pancreas, and bowel. There is attention to the effect of Epstein-Barr virus and infectious mononucleosis, seen very frequently in high school and collegiate athletes. Finally, groin pain and athletic pubalgia are described. In addition to anatomy and clinical presentation, imaging modalities that characterize such trauma are reviewed for each diagnosis. Prevention of thoracoabdominal injuries and return-to-play decisions are described at the chapter conclusion.
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15
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Yeung F, Chung PHY, Hung ELY, Yuen CS, Tam PKH, Wong KKY. Surgical Intervention for Primary Spontaneous Pneumothorax in Pediatric Population: When and Why? J Laparoendosc Adv Surg Tech A 2017; 27:841-844. [PMID: 28099064 DOI: 10.1089/lap.2016.0163] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Fanny Yeung
- Division of Paediatric Surgery, Department of Surgery, University of Hong Kong Medical Center , Queen Mary Hospital, Hong Kong, China
| | - Patrick H Y Chung
- Division of Paediatric Surgery, Department of Surgery, University of Hong Kong Medical Center , Queen Mary Hospital, Hong Kong, China
| | - Esther L Y Hung
- Division of Paediatric Surgery, Department of Surgery, University of Hong Kong Medical Center , Queen Mary Hospital, Hong Kong, China
| | - Chi Sum Yuen
- Division of Paediatric Surgery, Department of Surgery, University of Hong Kong Medical Center , Queen Mary Hospital, Hong Kong, China
| | - Paul K H Tam
- Division of Paediatric Surgery, Department of Surgery, University of Hong Kong Medical Center , Queen Mary Hospital, Hong Kong, China
| | - Kenneth K Y Wong
- Division of Paediatric Surgery, Department of Surgery, University of Hong Kong Medical Center , Queen Mary Hospital, Hong Kong, China
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16
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Pleural disease in infants and children: management updates. CURRENT PULMONOLOGY REPORTS 2016. [DOI: 10.1007/s13665-016-0134-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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17
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Soccorso G, Anbarasan R, Singh M, Lindley RM, Marven SS, Parikh DH. Management of large primary spontaneous pneumothorax in children: radiological guidance, surgical intervention and proposed guideline. Pediatr Surg Int 2015; 31:1139-44. [PMID: 26306420 DOI: 10.1007/s00383-015-3787-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Primary spontaneous pneumothorax (PSP) is managed in accordance with the adult British Thoracic Society (BTS) guidelines due to lack of paediatric evidence and consensus. We aim to highlight the differences and provide a best practice surgical management strategy for PSP based on experience of two major paediatric surgical centres. METHODS Retrospective review of PSP management and outcomes from two UK Tertiary Paediatric hospitals between 2004 and 2015. RESULTS Fifty children with 55 PSP (5 bilateral) were referred to our Thoracic Surgical Services after initial management: 53% of the needle aspirations failed. Nine children (20%) were associated with visible bullae on the initial chest X-ray. Forty-nine children were assessed with computed tomography scan (CT). Apical emphysematous-like changes (ELC) were identified in 37 children (75%). Ten children had also bullae in the asymptomatic contralateral lungs (20%). In two children (4%), CT demonstrated other lung lesions: a tumour of the left main bronchus in one child; a multi-cystic lesion of the right middle lobe in keeping with a congenital lung malformation in another child. Contralateral asymptomatic ELC were detected in 20% of the children: of those 40% developed pneumothorax within 6 months. Best surgical management was thoracoscopic staple bullectomy and pleurectomy with 11% risk of recurrence. Histology confirmed ELC in 100% of the apical lung wedge resections even in those apexes apparently normal at the time of thoracoscopy. CONCLUSION Our experience suggests that adult BTS guidelines are not applicable to children with large PSP. Needle aspiration is ineffective. We advocate early referral to a Paediatric Thoracic Service. We suggest early chest CT scan to identify ELC, for counselling regarding contralateral asymptomatic ELC and to rule out secondary pathological conditions causing pneumothorax. In rare instance if bulla is visible on presenting chest X-ray, thoracoscopy could be offered as primary option.
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Affiliation(s)
- Giampiero Soccorso
- Department of Paediatric Surgery, Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK.
| | - Ravindar Anbarasan
- Department of Paediatric Surgery, Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Michael Singh
- Department of Paediatric Surgery, Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Richard M Lindley
- Paediatric Surgical Unit, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Sean S Marven
- Paediatric Surgical Unit, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Dakshesh H Parikh
- Department of Paediatric Surgery, Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK
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18
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Maconochie IK, Howell A, Walton E. Spontaneous pneumothorax in children: the problem with rare presentations. Arch Dis Child 2015; 100:903-4. [PMID: 26141540 DOI: 10.1136/archdischild-2015-308309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 06/17/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Ian K Maconochie
- Department of Paediatric Emergency Medicine, Imperial College NHS Healthcare Trust, London, UK
| | - Andrew Howell
- Department of Paediatrics, Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Emily Walton
- Department of Paediatrics, Imperial College NHS Healthcare Trust, London, UK
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19
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Lamas-Pinheiro R, Branco-Salvador J, Jardim J, Ferraz C, Nunes T, Vaz LG, Azevedo I, Henriques-Coelho T. Management of pediatric primary spontaneous pneumothorax in a tertiary hospital. REVISTA PORTUGUESA DE PNEUMOLOGIA 2015; 21:S2173-5115(15)00130-X. [PMID: 26227223 DOI: 10.1016/j.rppnen.2015.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Revised: 06/17/2015] [Accepted: 06/17/2015] [Indexed: 06/04/2023] Open
Affiliation(s)
- R Lamas-Pinheiro
- Department of Pediatric Surgery, Hospital São João, Faculty of Medicine, Porto, Portugal.
| | - J Branco-Salvador
- Department of Pediatric Surgery, Hospital São João, Faculty of Medicine, Porto, Portugal
| | - J Jardim
- Department of Pediatric Pulmonology, Hospital São João, Faculty of Medicine, Porto, Portugal
| | - C Ferraz
- Department of Pediatric Pulmonology, Hospital São João, Faculty of Medicine, Porto, Portugal
| | - T Nunes
- Department of Pediatric Pulmonology, Hospital São João, Faculty of Medicine, Porto, Portugal
| | - L G Vaz
- Department of Pediatric Pulmonology, Hospital São João, Faculty of Medicine, Porto, Portugal
| | - I Azevedo
- Department of Pediatric Pulmonology, Hospital São João, Faculty of Medicine, Porto, Portugal
| | - T Henriques-Coelho
- Department of Pediatric Surgery, Hospital São João, Faculty of Medicine, Porto, Portugal
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