Primary spontaneous pneumothorax in children: A literature review

Use of Video-Assisted Thoracoscopic Surgery (VATS) in the Treatment of Primary Spontaneous Pneumothorax (PSP) in Children

INTRODUCTION

This study aims to review the primary spontaneous pneumothorax (PSP) patients we have treated and to discuss the results in terms of PSP treatment management and video-assisted thoracoscopic surgery (VATS) use in the light of the literature.

METHODS

The study was designed retrospectively and conducted at a tertiary referral university hospital between January 1, 2015 and May 1, 2021. Patients under the age of 18 years with a diagnosis of pneumothorax (PTX) were included in the study. Medical records were analyzed in terms of clinical characteristics, demographic data, findings from imaging data, procedures performed, and course of the disease at hospital. Patients with no evidence of PTX on radiologic imaging (direct postero-anterior chest X-ray (PACXR) or thoracic computed tomography (TCT)), incomplete medical records for follow-up, history of trauma, and neonatal PTX were excluded from the study.

RESULTS

The study was conducted on a total of 98 PTX cases in 69 patients, 61 (88.4%) males and eight (11.6%) females. The ages of the patients ranged between 13 and 17 years with a mean of 16.59 ± 0.95 years. While 48 (49%) PTX cases were treated with tube thoracostomy, 19 (19.4%) were treated with medical follow-up (nonsurgical treatment) and 31 (31.6%) were treated with VATS. A total of 31 VATS procedures were performed on 28 patients. The follow-up period after VATS ranged from tthree to 78 months, with a mean of 31.5 ± 20.3 months and a median of 28 months.

CONCLUSION

 Our retrospective study showed that TCT scanning did not provide additional benefit when PSP was detected on PACXR in patients presenting with chest pain and respiratory distress. According to the findings of our study, it was thought that the probability of undergoing an invasive procedure and surgical intervention increased as the percentage of PTX detected in PACXR increased. Tube thoracostomy may be required in a patient with PSP if PTX does not start to decrease and lung expansion does not increase after an average of 60 hours after the decision for medical follow-up, and if PTX is progressive in the follow-up. VATS can be performed on a patient with PSP when lung expansion does not increase after an average of 18 hours after tube thoracostomy, when PTX progresses, when air leakage continues for more than 10 days despite increased lung expansion, and when recurrent PTX occurs.

The Rare Presentation of Spontaneous Pneumothorax in a Pediatric Patient

Children presenting to the Emergency Department (ED) with upper respiratory infection (URI) symptoms of unresolved cough are not uncommon. Differentiation of the child's symptoms with thorough history and physical and when appropriate, further evaluation with blood work and imaging is the responsibility of the ED physician. In a clinical environment with increasing ED visits due to nonspecific URIs in children, it is also important not to overutilize an emergent workup with unnecessary testing. Our case involves a patient with atypical symptoms and hopes to highlight the importance of keeping a broad differential for all patients upon initial evaluation. Spontaneous pneumothorax is a potentially life-threatening condition. Our five-year-old patient presented with an unresolved cough being treated by an outpatient physician. He had no prior airway disease diagnosis. Severe cough in the absence of prior airway disease is notably less likely, but not an unseen cause of spontaneous pneumothorax. Our patient, however, developed just that. He was officially diagnosed with a right-sided pneumothorax on chest x-ray, underwent supplemental oxygen therapy, and was ultimately transferred to a pediatric hospital for continuation of care. Once there, our patient gradually improved was diagnosed as an asthmatic, and was started on appropriate maintenance medications. It is important to remain vigilant when examining multiple pediatric patients in a shift and to keep in mind that even otherwise healthy pediatric patients are at risk for spontaneous pneumothorax.  Spontaneous pneumothorax is a potentially life-threatening condition. Our five-year-old patient had no prior airway disease diagnosis making spontaneous pneumothorax notably less likely, however, from severe cough our patient developed just that. He was officially diagnosed with right-sided pneumothorax, underwent supplemental oxygen therapy, and was transferred to a pediatric hospital. Once there patient gradually improved, he was diagnosed as an asthmatic and started on appropriate medication to keep his breathing stable. It is essential to keep in mind that even otherwise pediatric patients are at risk for spontaneous pneumothoraxes and we as emergency physicians must keep this in mind during our evaluation.

Fifteen-minute consultation: A structured approach to a child with primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) is an uncommon presentation in children but may occur at any age and occurs in patients with no pre-existing lung disease. Management aims are to re-expand the collapsed lung, relieve pressure in the intrapleural space and avoid a tension pneumothorax. Correct management of PSP will avoid unnecessary intervention, reduce length of hospital stay and also reduce the risk of recurrence. There are no established guidelines for treating PSP in children and there is significant variation in management among centres and clinicians. This article provides a clear, evidence-based and structured approach to assessment and management of PSP in children and young people.

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.

Histopathologic Findings Associated With Matrix Metalloproteinases Proceeding to Recurrence of Primary Spontaneous Pneumothorax in Adolescents

Background: Primary spontaneous pneumothorax is potentially life-threatening, and its recurrence is always a serious problem. Pathological examination provides molecular insights into the pathophysiology of primary spontaneous pneumothorax. Objectives: To investigate the association of histopathologic features of primary spontaneous pneumothorax with matrix metalloproteinase expression and their relevance to the recurrence. Methods: A total of 217 tissue section slides in 172 adolescent patients with primary spontaneous pneumothorax were retrospectively reviewed from January 2001 to June 2020. All histopathologic features were recorded and pathologic findings related to ipsilateral recurrence and second surgery were analyzed. Serum levels of matrix metalloproteinases were prospectively measured in 25 primary spontaneous pneumothorax patients receiving surgery and 18 healthy controls. Their relevance to the histopathologic features of primary spontaneous pneumothorax related to its recurrence was also examined. Results: The major presenting histopathologic findings of primary spontaneous pneumothorax were bleb/bulla (98%) followed by fibrosis (68%). Low prevalence of the pathologic findings of granulation tissue and macrophage accumulation were significantly associated with recurrent primary spontaneous pneumothorax, whereas fibrosis was significantly higher in patients receiving more than once surgery. Furthermore, the ratios of matrix metalloproteinase-2/tissue inhibitor of metalloproteinase-1 and matrix metalloproteinase-9/tissue inhibitor of metalloproteinase-1 were significantly higher in theses pathological findings as well as multinucleated giant cells and mesothelial cell hyperplasia in comparison with healthy controls. Conclusions: Low prevalence of macrophage accumulation and granulation tissue related to the overexpression of matrix metalloproteinase-2 and-9 activities may contribute to healing impairment and primary spontaneous pneumothorax recurrence.

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

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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.

Primary spontaneous pneumothorax in children: factors predicting recurrence and contralateral occurrence

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.