What factors predict recurrence after an initial episode of primary spontaneous pneumothorax in children?

[Diagnosis and management of idiopathic spontaneous pneumothorax in adolescents]

INTRODUCTION

Due to the absence of consensual definition and agreed-upon pediatric treatment, pneumothorax (PNO) in children and adolescents often remains difficult to properly apprehend.

STATE OF THE ART

While initial diagnostic suspicion is clinical, confirmation necessitates chest imaging, and lung ultrasound has become increasingly prevalent, often at the expense of chest radiography. The goal of treatment is twofold, on the one hand to a fully re-expand the lungs, and on the other hand to forestall PNO recurrence. Depending on PNO severity and clinical tolerance, it may be advisable to envision conservative management, oxygen supplementation, needle exsufflation, or chest tube drainage.

PERSPECTIVES

In order to harmonize clinical practices, guidelines for the precise definition and graduated management of PNO in children and adolescents are highly advisable.

CONCLUSIONS

Idiopathic spontaneous PNO frequently occurs in teenage populations, and its likewise frequent recurrence is not satisfactorily predicted by chest CT findings. It is of paramount importance that patients be fully informed of the risk of recurrence.

Pneumothorax and pneumomediastinum in children

Pneumothorax is a condition that describes the presence of air between the visceral and parietal pleura sheets and the consequent collapse of the lungs. The collapse of the lungs can be partial or total and can present in different clinical stages, such as a high-pressure pneumothorax that can cause a mediastinal shift. Pneumomediastinum is the presence of free air between the mediastinal tissues due to various causes. It can manifest spontaneously and be minimally symptomatic but can also develop due to severe complications. Its etiology includes numerous iatrogenic and traumatic factors. Although spontaneous pneumothorax and pneumomediastinum that develop in childhood are similar to adult patients, it is important to determine the appropriate treatment strategy in addition to the age group, the effectiveness of the treatment, the role of the applied treatment in reducing recurrence, and the etiologyoriented treatments if there is an underlying pathology.

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.

Management of primary spontaneous pneumothorax in children: Current practices among Turkish pediatric surgeons

Background

This study aims to evaluate current practices in the management of primary spontaneous pneumothorax among Turkish pediatric surgeons.

Methods

Between October 2021 and November 2021, an online survey comprising 19 questions was delivered to all members of the Turkish Association of Pediatric Surgeons (TAPS). A total of 74 respondents (42 males, 32 females; mean age: 42.3±7.9 years; range, 29 to 61 years) were included.

Results

The response rate was 17.1% among all society members. The rate of utilization of computed tomography in the initial admission was 27.4%, and the rate of use in cases requiring surgical treatment was 78.4%. A total of 81% of surgeons reported that the size of the pneumothorax influenced management. For the first episode of primary spontaneous pneumothorax, 75.7% of surgeons opted for chest tube drainage, 14.9% for only oxygen administration, 4.1% for needle aspiration, and none of the surgeons preferred video-assisted thoracoscopic surgery. For patients with a persistent air leak after chest tube placement, there was a wide variation in the duration of observation before performing surgery. Video-assisted thoracoscopic surgery was the most preferred surgical intervention (75.3%) and the most preferred surgical method was stapled bullectomy (43.8%).

Conclusion

There are practice variations in the management of pediatric primary spontaneous pneumothorax among the society members. However, the majority of members seem to agree on the use of computed tomography, initial treatment, and surgical interventions.

Pediatric primary spontaneous pneumothorax: a comparison of treatment at pediatric surgery vs. thoracic surgery departments

Management of pediatric Primary Spontaneous Pneumothorax (PSP) is controversial and based on guidelines on adults. Therapeutic strategies include: observation, needle aspiration, chest drain, or surgery. We aimed to assess: i) differences in the management of PSP in pediatric vs. adult departments; ii) risk of recurrence associated to each therapeutic choice; iii) management of "large" pneumothorax (i.e. >3cm at the apex on chest X-Ray); iv) role of CT scan in addressing the treatment. We reviewed all PSP treated at Pediatric Surgery Unit (PSU) and Thoracic Surgery Unit for adults (TSU) in a 10-year period (2011 to 2020). We included a total of 42 PSP: 30/42 1st episodes and 12/42 recurrences. Among the 30/42 1st episodes, 15/30 were managed in the PSU and 15/30 in the TSU. Observation was significantly most common among PSU patients (9/15, 60%) vs. TSU cases (1/15, 6.7%; p=0.005]. Chest drain placement was reduced in PSU (3/15, 20%) vs. TSU (12/15, 80%; p=0.002). Observational was associated with a reduced risk of recurrence (0/10, 0%) compared to chest drain (7/15, 46.7%; p=0.01). Management of 20/42 "large" pneumothorax was: 4/20 (20%) observation, 10/20 (50%) chest drain, 2/20 (10%) needle aspiration, 4/20 (20%) surgery. Twentythree/ 29 PSP (79.3%) underwent CT-scan after the first episode. Bullae were detected in 17/23 patients and 5/17 (29.4%) had seven episodes of recurrence. PSP patients treated by PSU were more likely to receive clinical observation. Those managed by TSU were mostly treated by chest drain. Observation seems an effective choice for clinically stable PSP, with low risk of recurrence at a mid-term follow-up. CT-scan seems not to detect those patients at higher risk of recurrence.

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.

Early risk factors of operative management for hospitalization children with spontaneous pneumothorax

BACKGROUND

The optimal timing of operative management in children with primary spontaneous pneumothorax (PSP) remains controversial. This study sought to determine early risk factors for failure of chest tube nonoperative management during the initial hospitalization in adolescents with PSP.

METHODS

A retrospective review was conducted for children (aged ≤18 years) admitted to a single tertiary care referral center for their first presentation of a PSP managed with at least 48 h of chest tube decompression (CTD) alone. Patient outcomes and early risk factors for operative management were analyzed by multivariate regression.

RESULTS

Of the 39 patients who met inclusion criteria, 15 (38.5%) patients failed nonoperative treatment while 24 (61.5%) patients were managed with CTD therapy alone. Progression to thoracoscopic surgery was associated with longer CTD of 8 vs 3 days and hospital length of stay of 9 vs 4 days when compared to nonoperative management (p < 0.001, both). Air leak and increase in pneumothorax size at 24 h after CTD were independently associated with progression to surgery (p = 0.007, p = 0.002). Combined, these risk factors were associated with a significant increase in recurrence (OR 6.00, 95% CI 1.11-41.11, p = 0.048). There were no significant differences between PSP management strategies regarding cumulative radiation exposure or 2 year recurrence.

CONCLUSIONS

Air leak or increasing pneumothorax size within 24 h of CTD are highly correlated with failed nonoperative management during the initial hospitalization in pediatric patients with PSP. This data may be useful in the development of pediatric-specific treatment algorithms to optimally manage these patients.

LEVEL OF EVIDENCE

Treatment study, Level III.

Meta-analysis of the association between emphysematous change on thoracic computerized tomography scan and recurrent pneumothorax

OBJECTIVES

At least a third of patients go on to suffer a recurrence following a first spontaneous pneumothorax. Surgical intervention reduces the risk of recurrence and has been advocated as a primary treatment for pneumothorax. But surgery exposes patients to the risks of anaesthesia and in some cases can cause chronic pain. Risk stratification of patients to identify those most at risk of recurrence would help direct the most appropriate patients to early intervention. Many studies have addressed the role of thoracic computerized tomography (CT) in identifying those individuals at increased risk of recurrence, but a consensus is lacking.

AIM

Our objective was to clarify whether CT provides valuable prognostic information for recurrent pneumothorax.

DESIGN

Meta-analysis.

METHODS

We conducted an exhaustive search of the literature for thoracic CT imaging and pneumothorax, and then performed a meta-analysis using a random effects model to estimate the common odds ratio and standard error.

RESULTS

Here, we show by meta-analysis of data from 2475 individuals that emphysematous change on CT scan is associated with a significant increased odds ratio for recurrent pneumothorax ipsilateral to the radiological abnormality (odds ratio 2.49, 95% confidence interval 1.51-4.13).

CONCLUSIONS

The association holds true for primary spontaneous pneumothorax when considering emphysematous changes including blebs and bullae. Features, such as bullae at the azygoesophageal recess or increased Goddard score similarly predicted recurrent secondary pneumothorax, as shown by subgroup analysis. Our meta-analysis suggests that CT scanning has value in risk stratifying patients considering surgery for pneumothorax.

Management of primary spontaneous pneumothorax in teenagers: An 11-year study

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.

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.

Early Postoperative Pneumothorax Might Not Be 'True' Recurrence

Objectives: To date, there is no consensual definition of what constitutes a postoperative recurrence of primary spontaneous pneumothorax (PSP), despite there being many studies reporting a high incidence of recurrence. This study aims to describe the long-term recurrence rates of pneumothorax and to suggest a possible way to differentiate recurrence events based on temporal patterns. Methods: This single-center study retrospectively evaluated all postoperative recurrence of PSP from January 2007 to May 2019. Patients’ demographics, history of pneumothorax, radiologic data, surgical technique, and the time between operation and recurrence were analyzed. Univariate and multivariable analyses were conducted to find potential risk factors related to long-term recurrence. Results: Of the 77 postoperative recurrent cases of pneumothorax, 21 (27.2%) occurred within 30 days after surgery and, thus, were classified as early recurrences (ER), while the remaining cases were classified as late recurrences (LR). There was no difference in preoperative variables between the two groups. However, the rate of incidence of second recurrence (SR), which represented a long-term prognosis, was significantly higher in the LR group (28.6% vs. 4.8%, p = 0.030). On univariate and multivariable analyses, late recurrence was the only significant factor predicting later recurrence events. Conclusion: Postoperative recurrence (PoR) within 30 days had a lower SR rate. Therefore, it might not be a ‘true’ postoperative recurrence with a favorable prognosis. Further studies investigating postoperative recurrence based on temporal patterns would be warranted to improve the classification of PoR.

Early Surgery for Spontaneous Pneumothorax Associated With Reduced Recurrence, Resource Utilization

BACKGROUND

Primary spontaneous pneumothorax (PSP) occurs in adolescent patients and frequently recurs. Reliable predictors of recurrence may identify candidates for early VATS (video-assisted thoracoscopic surgery). We hypothesize that demographic and clinical factors are associated with recurrence, and that earlier surgery is associated with decreased recurrence and resource utilization.

METHODS

Patients between ages 5 and 21 treated for PSP at a single center from January 1, 2008 to June 30th, 2019 were identified. Presenting demographics, clinical management, and outcomes were analyzed, with focus on the first admission for PSP. "Early VATS" was defined as VATS during the first admission, and "late VATS" as VATS at any point after the first admission for a given side.

RESULTS

Thirty-nine patients met inclusion criteria, with a total of 82 pneumothoraces. Following initial encounter, 48.7% had ipsilateral recurrence. Early VATS was associated with less recurrence (P = 0.002). No other predictive factors were associated with ipsilateral recurrence. Early VATS was associated with reduced overall recurrence (P < 0.001), admissions (P < 0.001), cumulative chest x-rays (P = 0.043), and cumulative hospital length of stay (P = 0.022) compared to late VATS.

CONCLUSIONS

While predictors of recurrence are not apparent at initial admission, early VATS is associated with decreased recurrence and resource utilization.

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.

Recurrence of spontaneous pneumothorax six years after VATS pleurectomy: evidence for formation of neopleura

Background

Primary Spontaneous Pneumothorax (PSP) is considered an absolute and definitive contraindication for scuba diving and professional flying, unless bilateral surgical pleurectomy is performed. Only then is there a sufficiently low risk of recurrence to allow a waiver for flying and/or diving.

Case presentation

A young fit male patient who suffered a PSP 6 years ago, and underwent an uncomplicated videoscopic surgical pleurectomy, presented with a complete collapse of the lung on the initial PSP side. Microscopic examination of biopsies showed a slightly inflamed tissue but otherwise normal mesothelial cells, compatible with newly formed pleura.

Conclusions

Even with pleurectomy, in this patient, residual mesothelial cells seem to have had the capacity to create a completely new pleura and pleural space. The most appropriate surgical technique for prevention of PSP may still be debated.

Age and Clinical Presentation for Primary Spontaneous Pneumothorax

Primary spontaneous pneumothorax (PSP) is a commonly known condition due to the accumulation of air in the pleural space in otherwise healthy people, without apparent underlying lung disease. To date, the exact pathogenesis of PSP is unclear, but it still represents a public health issue. We performed a review of the literature concerning the epidemiology of PSP, examining age of onset and presentation symptoms, in order to assess the possible correlation between these characteristics and its occurrence. Data concerning age, signs, and symptoms were collected. For description purposes, information regarding aetiological and anthropomorphic data was also gathered. In total, 265 papers were evaluated. Regarding age of onset, PSP is a disease that can occur in a broad age group with a double cluster (15-30 and 40-45 yr). Regarding symptoms, pain and dyspnoea (in its various forms) are the most described in PSP. Pain was recorded in 69.25% (range, 9-100%) of the population studied, whereas dyspnoea was present in an average of 54.55% (range, 27-77.1%). Tobacco exposure seems to play an important role in the early onset of PSP. Concerning age at presentation, this review highlights that PSP can occur over a broad age range. The literature appears to be consistent in reporting PSP occurrence mostly below 45 years of age. Asymptomatic PSP is an almost unseen entity. Finally, of pollutants, cigarette smoking should be considered as the most significant exogenous risk factor in the development of PSP.

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.

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.

Changing the Paradigm for Management of Pediatric Primary Spontaneous Pneumothorax: A Simple Aspiration Test Predicts Need for Operation

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.

Risk factors for recurrence of primary spontaneous pneumothorax after thoracoscopic surgery

Background

Recurrence of pneumothorax after thoracoscopic surgery is a concerning issue for thoracic surgeons. In this study, we aimed to determine the risk factors for recurrence of spontaneous pneumothorax after thoracoscopic surgery.

Methods

A total of 192 patients with spontaneous pneumothorax aged <50 years who underwent thoracoscopic surgery from January 2010 to December 2016 were included in this study. Pre- and post-operative characteristics were obtained from medical records, and recurrent and non-recurrent cases were compared.

Results

Fourteen patients (7.3%) experienced pneumothorax recurrence. Pneumothorax recurrence was observed more frequently in patients aged <20 years (P=0.041) and those in whom bullae were not identified on preoperative computed tomography (CT) (P=0.049). The use of polyglycolic acid (PGA) sheets during surgery significantly decreased the recurrence rate (P=0.031). A history of ipsilateral pneumothorax before surgery was a significant risk factor for recurrence after thoracoscopic surgery (P=0.001). In the multivariate analysis, a history of ipsilateral pneumothorax and identification of bullae on CT were identified as significant risk factors for recurrence.

Conclusions

A history of ipsilateral pneumothorax, and inability to identify bullae on preoperative CT were risk factors for postoperative recurrence of pneumothorax.

Management and recurrence of spontaneous pneumothorax in children

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.

Current Practice in the Management of Spontaneous Pneumothorax in Children

INTRODUCTION

There is a lack of pediatric-specific guidelines for the workup and management of primary spontaneous pneumothorax (PSP) in children. The aim of this study was to describe current practices among North American pediatric surgeons.

MATERIALS AND METHODS

An online survey comprising 18 questions was sent out through the American Pediatric Surgical Association Outcomes and Clinical Trials Committee to all members. Bivariate analysis was performed using Chi-square analysis.

RESULTS

A total of 287 surveys were completed (33% response rate). For a first episode of PSP, 57% of surgeons opt for chest tube drainage, 4% for upfront video-assisted thoracoscopic surgery (VATS), 3% for needle aspiration, and 29% for only oxygen administration. Eighty-one percent of surgeons report that the size of the pneumothorax influences management. However, neither practice setting (P = .87) nor years in practice (P = .11) correlated with initial management strategy. For patients with a persistent air leak after chest tube placement, there is wide variation in duration of observation before performing VATS, with 40% operating after 3 days, but 21% waiting at least 5 days. The use of chest computed tomography (CT) is also highly variable. Eighty-two percent of respondents perform surgery only after the second episode of PSP. Most perform a stapled apical blebectomy and mechanical pleurodesis for both initial and recurrent PSP.

CONCLUSION

There is significant variation among pediatric surgeons in the management of spontaneous pneumothorax, including the use of CT, timing of operation, and duration of observation for air leak before performing surgery. Prospective data are needed to better inform guidelines and standardize practice.

Initial primary spontaneous pneumothorax in children and adolescents: Operate or wait?

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.

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.

Spontaneous Pneumothorax in Children: National Management Strategies and Outcomes

INTRODUCTION

The timing of surgical intervention in the management of spontaneous pneumothorax remains controversial. The aim of this multicenter review was to compare management strategies and outcomes in children with spontaneous pneumothorax.

METHODS

We retrospectively reviewed patients 10-19 years old in the Pediatric Health Information System admitted for spontaneous pneumothorax from 2010 to 2014. Three treatment groups were identified based on initial hospital management-no intervention, initial chest tube placement, and operation; and outcomes were compared.

RESULTS

A total of 1040 patients were included. The majority were male (82.1%) and White (71.1%). The mean age at first encounter was 15.7 ± 1.7 years. Initial treatment included no intervention in 336 (32.3%), chest tube in 497 (47.8%), and video-assisted thoracoscopic surgery (VATS) in 207 (19.9%). Ultimately, 417 (40.1%) patients underwent VATS during the initial admission and 559 (53.8%) during the initial admission or a subsequent encounter. Aggregate length of stay (LOS) was highest for those treated initially with chest tube alone (P < .001). For patients managed initially with chest tube, the probability of requiring surgery increased with each day of hospitalization. Initial operation was associated with a decreased risk of readmission (OR 0.67, 95% CI 0.50-0.90). Estimated adjusted hospital costs, aggregated across all encounters, were highest for chest tube alone (P < .001).

CONCLUSION

Early VATS is associated with decreased hospital LOS, charges, and readmissions. For those managed initially with chest tube alone, the likelihood of requiring operation increases with each day hospitalized, and early conversion to operative management should be considered in patients with persistent pneumothorax or air leak.

Association Between BMI and Recurrence of Primary Spontaneous Pneumothorax

BACKGROUND

Whether body mass index (BMI) is a significant risk factor for recurrence of primary spontaneous pneumothorax (PSP) remains controversial. The purpose of this study was to examine whether BMI and other factors are linked to risk of PSP recurrence.

METHODS

A consecutive cohort of 273 patients was retrospectively evaluated. Patients were divided into those who experienced recurrence (n = 81) and those who did not (n = 192), as well as into those who had low BMI (n = 75) and those who had normal or elevated BMI (n = 198). The two pairs of groups were compared in terms of baseline data, and Cox proportional hazards modeling was used to identify predictors of PSP recurrence.

RESULTS

Rates of recurrence among all 273 patients were 20.9% at 1 year, 23.8% at 2 years, and 28.7% at 5 years. Univariate analysis identified the following significant predictors of PSP recurrence: height, weight, BMI, size of pneumothorax, and treatment modality. Multivariate analyses identified several risk factors for PSP recurrence: low BMI, pneumothorax size ≥50%, and non-surgical treatment. Kaplan-Meier survival analysis indicated that patients with low BMI showed significantly lower recurrence-free survival than patients with normal or elevated BMI (P < 0.001).

CONCLUSIONS

Low BMI, pneumothorax size ≥50%, and non-surgical treatment were risk factors for PSP recurrence in our cohort. Low BMI may be a clinically useful predictor of PSP recurrence.

Postoperative predictors of ipsilateral and contralateral recurrence in patients with primary spontaneous pneumothorax

BACKGROUND

Preventive surgery for contralateral recurrence of primary spontaneous pneumothorax (PSP) remains controversial and few studies discussed both ipsilateral and contralateral recurrences simultaneously. Thus, we aimed to identify the predictors of ipsilateral and contralateral PSP recurrence and to review literatures on the association of blebs/bullae on HRCT with PSP recurrence.

METHODS

We retrospectively reviewed consecutive patients who were treated at our hospital for first recurrence of PSP between January 2001 and December 2005.

RESULTS

This study included 553 patients who were followed-up for a mean period of 124 months. Ipsilateral and contralateral recurrence of PSP developed in 19.35% and 15.19% of patients, respectively. In the Cox regression analysis, the only significant predictors were no video-assisted thoracoscopic surgery (VATS) bullectomy (OR: 16.629, P<0.001) for ipsilateral recurrence, and the presence of blebs/bullae on HRCT (OR: 3.215, P=0.024) and low BMI (<18.5 kg/m²) (OR: 1.560, P=0.045) for contralateral recurrence.

CONCLUSIONS

VATS bullectomy was a strong independent predictor for prevention of ipsilateral PSP recurrence. Patients with contralateral blebs or bullae on chest HRCT or those with low BMI may be candidates for preventive VATS bullectomy to avoid recurrences and possible complications.

A novel structural risk index for primary spontaneous pneumothorax: Ankara Numune Risk Index

BACKGROUND

In this study, we aimed to reveal a novel risk index as a structural risk marker for primary spontanoeus pneumothorax using body mass index and chest height, structural risk factors for pneumothorax development.

METHODS

Records of 86 cases admitted between February 2014 and January 2015 with or without primary spontaneous pneumothorax were analysed retrospectively. The patients were allocated to two groups as Group I and Group II. The patients were evaluated with regard to age, gender, pneumothorax side, duration of hospital stay, treatment type, recurrence, chest height and transverse diameter on posteroanterior chest graphy and body mass index. Body mass index ratio per cm of chest height was calculated by dividing body mass index with chest height. We named this risk index ratio which is defined first as 'Ankara Numune Risk Index'. Diagnostic value of Ankara Numune Risk Index value for prediction of primary spontaneous pneumothorax development was analysed with Receiver Operating Characteristics curver.

RESULTS

Of 86 patients, 69 (80.2%) were male and 17 (19.8%) were female. Each group was composed of 43 (50%) patients. When Receiver Operating Characteristics curve analysis was done for optimal limit value 0.74 of Ankara Numune Risk Index determined for prediction of pneumothorax development risk, area under the curve was 0.925 (95% Cl, 0.872-0.977, p < 0.001).

CONCLUSIONS

Ankara Numune Risk Index is one of the structural risk factors for prediction of primary spontaneous pneumothorax development however it is insufficient for determining recurrence.

Apex-to-Cupola Distance Following VATS Predicts Recurrence in Patients With Primary Spontaneous Pneumothorax

Our study sought to determine whether the size of the residual apical pleural space in young patients with primary spontaneous pneumothorax (PSP) following video-assisted thoracoscopic surgery is associated with the risk of recurrence. We retrospectively reviewed patients (≤30 years' old) with primary spontaneous pneumothorax following thoracoscopic surgery (2002-2010) in a university-affiliated hospital. The size of residual apical pleural space was estimated by measuring the apex-to-cupola distance on a postoperative chest radiograph at 2 time windows: first between postoperative day (POD) 0 and 3, and second between POD 4 and 14. A total of 149 patients were enrolled with a median follow-up of 11.2 months (interquartile range, 0.95-29.5 months), of whom 141 (94.6%) were male with a mean age of 20 years. The postoperative recurrence rate was 11.4%. Comparing the characteristics between the patients with and without recurrent pneumothorax, the patients with recurrence were younger (18.2 + 2.4 vs 20.7 + 3.7 years, P = 0.008), with a lower rate of pleurodesis (35% vs1 69%, P = 0.037), longer apex-to-cupola distance at POD 0 to 3 (22.41 ± 19.56 vs 10.07 ± 10.83 mm, P < 0.001) and POD 4 to 14 (11.82 ± 9.75 vs 5.54 ± 8.38 mm, P = 0.005) than the patients without recurrence. In a multivariate logistic regression model for recurrent pneumothorax, age <18 years (P = 0.026, odds ratio [OR]: 4.694), apex-to-cupola distance at POD 0 to 3 >10 mm (P = 0.027, OR: 5.319), and no pleurodesis during VATS (P = 0.022, OR: 5.042) were independent risk factors for recurrent pneumothorax. The recurrence rate was not low (11.4%) in young patients with PSP following VATS. Residual apical pleural space with apex-to-cupola distance of 10 mm or greater at POD 0 to 3, younger age, and no pleurodesis would increase postoperative recurrence of primary spontaneous pneumothorax.

Do atmospheric conditions influence the first episode of primary spontaneous pneumothorax?

OBJECTIVES

Several studies suggest that changes in airway pressure may influence the onset of primary spontaneous pneumothorax (PSP). The aim of this study was to investigate the influence of atmospheric changes on the onset of the first episode of PSP.

METHODS

We retrospectively analysed cases of pneumothorax admitted to our department between 1 January 2009 and 31 October 2013. Patients with recurrent pneumothorax, traumatic pneumothorax, older than 35 years or presenting history of underlying pulmonary disease were excluded. Meteorological data were collected from the Météo-France archives. Variation (Δ) of mean atmospheric pressure, and relative humidity, were calculated for each day between the day at which symptoms began (D-day), the day before first symptoms (D-1), 2 days before the first symptoms (D-2) and 3 days before the first symptoms (D-3).

RESULTS

Six hundred and thirty-eight cases of pneumothorax were observed during the period of this study; 106 of them (16.6%) were a first episode of PSP. We did not observe any significant differences between days with or without PSP admission for any of the weather parameters that we tested. We could not find any thresholds in the variation of atmospheric pressure that could be used to determine the probability of PSP occurrence.

CONCLUSIONS

Variation of atmospheric pressure, relative humidity, rainfall, wind speed and temperature were not significantly related to the onset of the first episode of PSP in healthy patients. These results suggest that the scientific community should focus on other possible aetiological factors than airway pressure modifications.

Recurrence of primary spontaneous pneumothorax in young adults and children

OBJECTIVES

Although better nutritional support has improved the growth rates in children, the occurrence of primary spontaneous pneumothorax has also been increasing in children. The current study attempts to investigate the occurrence and recurrence of primary spontaneous pneumothorax and the efficacy of surgery for primary spontaneous pneumothorax in young adults and children.

METHODS

A total of 840 patients were treated for pneumothorax at our hospital from January 2006 to December 2010. Exclusion criteria for this study were age >25 or secondary, traumatic or iatrogenic pneumothorax, and a total of 517 patients were included. Patients were classified into three groups according to age at the first episode of primary spontaneous pneumothorax: Group A: ≤16 years; Group B: 17-18 years and Group C: ≥19 years.

RESULTS

The study group was composed of 470 male and 47 female patients. There were 234 right-sided, 279 left-sided and 4 bilateral primary spontaneous pneumothoraces. Wedge resection by video-assisted thoracic surgery was performed in 285 patients, while 232 were managed by observation or closed thoracostomy. In the wedge resection group, 51 patients experienced recurrence. The recurrence rates after wedge resection were 27.9% in Group A, 16.5% in Group B and 13.2% in Group C (P = 0.038). The recurrence rates after observation or closed thoracostomy were 45.7% in Group A, 51.9% in Group B and 47.7% in Group C (P = 0.764).

CONCLUSIONS

In the present study, postoperative recurrence rates were higher than those in the literature. Intense and long-term follow-up was probably one reason for the relatively high recurrence rate. The recurrence rate after wedge resection in patients aged ≤16 years was higher than that in older patients. There was no difference between the recurrence rates after observation or closed thoracostomy, regardless of age. These results suggest that wedge resection might be delayed in children.