Pneumothorax In Pediatric Patients: Management Strategies To Improve Patient Outcomes

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Epidemiology
6. Pathophysiology
   1. Types Of Pneumothoraces
      1. Primary Spontaneous Pneumothorax
      2. Secondary Pneumothorax
      3. Neonatal Pneumothorax
      4. Traumatic Pneumothorax
      5. Open Pneumothorax
      6. Occult Pneumothorax
      7. Tension Pneumothorax
      8. Iatrogenic Pneumothorax
7. Differential Diagnosis
8. Prehospital Care
   1. Air Transport
   2. Ground Transport
   3. Positive-Pressure Ventilation
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
   3. Early Intervention
10. Diagnostic Studies
    1. Imaging Studies
       1. Chest Radiography
       2. Point-Of-Care Ultrasound
          • Findings In Normal Lungs
          • Findings Suggestive Of Pneumothorax
       3. Computed Tomography
    2. Size Quantification Of A Pneumothorax
       1. The Rhea Average Interpleural Distance Method
       2. The Light Index
       3. The Collins Method
       4. Comparison Of The Efficacy Of The Methods
       5. Comparison Of Diagnostic Studies For Quantifying Pneumothorax Size
       6. Management Based On Pneumothorax Size
11. Treatment
    1. Spontaneous Pneumothoraces
    2. Large Or Symptomatic Primary Spontaneous Pneumothoraces
    3. Surgical Method
    4. Modified Seldinger Technique
    5. Connection To A Drainage System
    6. Additional Surgical Interventions
    7. Complications Of Needle Thoracostomy, Placement Of Intercostal Catheters, And Tube Thoracostomy
12. Special Circumstances
    1. Secondary Pneumothoraces
    2. Open Pneumothoraces
    3. Occult Pneumothoraces
    4. Tension Pneumothoraces
       1. Interventions And Complications
13. Controversies And Cutting Edge
    1. Prehospital Use Of Ultrasound To Identify Pneumothoraces
    2. Outpatient Management With Chest Tubes
    3. Telemedicine Guidance Of Chest Tube Placement
14. Disposition
15. Summary
16. Risk Management Pitfalls In Pediatric Patients With A Pneumothorax
17. Time- And Cost-Effective Strategies
18. Case Conclusions
19. Clinical Pathway For Management Of Pediatric Patients With Pneumothorax
20. Tables and Figures
    1. Table 1. Types And Characteristics Of Pneumothoraces
    2. Table 2. Diseases And Conditions That Increase The Risk Of Secondary Pneumothorax
    3. Table 3. Signs And Symptoms Of Pneumothorax
    4. Table 4. Imaging Modalities For Pneumothorax And Potential Findings
    5. Table 5. Definitions Of Large Pneumothoraces
    6. Table 6. Chest Tube Selection For The Surgical Method As Determined By Patient Weight
    7. Figure 1. Pneumothorax On Chest Radiography
    8. Figure 2. Deep Sulcus Sign On Chest Radiography
    9. Figure 3. Scapula And Skin Fold Mimicking Pneumothorax
    10. Figure 4. Normal Lung Findings On Thoracic Ultrasound
    11. Figure 5. Absence Of Lung Sliding Suggestive Of Pneumothorax
    12. Figure 6. The Surgical Method
    13. Figure 7. The Modified Seldinger Technique
    14. Figure 8. Evolving Tension Pneumothorax
21. References

Abstract

The clinical presentation of pneumothorax is highly variable. Spontaneous pneumothoraces may present with subtle symptoms when a small air leak is present, but can progress to hemodynamic instability in the setting of tension physiology. The etiologies are broad and the severity can vary greatly. A trauma patient with a pneumothorax may also have the added complexity of other potentially life-threatening injuries. While there is a wealth of evidence-based guidelines for the management of pneumothoraces in the adult literature, the approach to pediatric patients is largely extrapolated from that literature without a significant evidence base. In this issue, aspects of the history and physical examination, the use of various diagnostic imaging modalities, and the range of interventions available to the emergency clinician are discussed.

Case Presentationss

A 12-year-old boy is brought in by EMS with a single stab wound to the right lower-anterior chest. He is alert and oriented, but noted to be tachycardic, borderline hypotensive, and agitated. During your primary survey, you note that his airway is intact. Breath sounds on the left are normal, but there is no air movement on the right. There is a small laceration to the right anterior chest. Peripheral pulses are present but thready, and capillary refill is noted to be 4 to 5 seconds. You place the patient on supplemental oxygen and obtain IV access with 2 large-bore lines. The patient begins to decompensate and becomes anxious and combative. His blood pressure is now 62/30 mm Hg. What are the immediate life-threatening conditions you need to consider? What tools do you have at your disposal to make an appropriate diagnosis? As your heart races, you consider the possibility of a tension pneumothorax and life-threatening intrathoracic or intra-abdominal bleeding. Do you place a surgical thoracostomy tube? A pigtail catheter? Transfuse blood? What life-saving maneuvers should you perform immediately?

A 15-year-old boy then presents for evaluation of acute-onset chest pain and shortness of breath. The patient states that he felt sudden, sharp, right-sided chest pain in class an hour ago. The patient denies fever, upper respiratory symptoms, cough, nausea, vomiting, or diarrhea. There is no report of travel or trauma. The patient does report frequent marijuana and cigarette smoking. His vital signs are: heart rate, 94 beats/min; blood pressure, 112/70 mm Hg; respiratory rate, 18 breaths/min; and oxygen saturation, 97% on room air. Lung sounds are slightly diminished on the right. You send the patient for a chest x-ray and begin to consider management options. Are there other aspects of the history you should obtain? Should you order a chest CT to look for blebs or other malformations? Should you order screening labs or place a thoracostomy tube or a pigtail catheter? Should you admit this patient?

Introduction

A pneumothorax is the pathologic collection of air within the pleural space, which is a potential space between the visceral and pleural lining. A pneumothorax can be the result of a spontaneous perforation of the lung parenchyma, chest wall trauma, disruption of the bronchotracheal tree, or, rarely, it may be iatrogenic in nature. A pneumothorax represents many different disease entities that may vary greatly in severity. Pneumothoraces are classically divided into 2 distinct categories: spontaneous and secondary. Spontaneous pneumothoraces, are idiopathic, without obvious cause. Secondary pneumothoraces occur in the setting of trauma or an underlying condition, or they may be iatrogenically induced in patients after thoracic surgery, placement of a central venous catheter, or intubation.

Most data regarding the management of pneumothorax in the pediatric population are extrapolated from literature that evaluates primarily adult patients, with few papers and no randomized controlled trials evaluating pediatric patients or producing pediatric management guidelines.¹ There are no standardized guidelines promoting specific diagnostic modalities or therapeutic interventions for children with pneumothorax; however, early identification and appropriate management can reduce morbidity and mortality. In this issue of Pediatric Emergency Medicine Practice, the epidemiology, pathophysiology, diagnosis, and management of pneumothorax as relevant to practice in the emergency department (ED) are reviewed.

Critical Appraisal Of The Literature

A review of the relevant literature was performed using PubMed, Google Scholar, MEDLINE^®, and the Cochrane Database of Systematic Reviews, with search terms including: pneumothorax, pneumothoraces, pediatric pneumothorax, thoracic trauma, tube thoracostomy, pigtail catheter, simple aspiration, lung ultrasound, focused assessment with sonography in trauma (FAST), and pre-hospital care. A total of 163 articles published over the past 3 decades were reviewed. A search of the Cochrane Database of Systematic Reviews for the terms pediatric pneumothorax and pneumothoraces in children did not produce any results. Guidelines from the American College of Chest Physicians (ACCP) from 2001², British Thoracic Society (BTS) from 2003³, and Belgian Society of Pneumology (BSP) from 2005⁴ presented excellent, evidence-based approaches to pneumothorax in adults, but offered no specific guidance to management in the pediatric population. With these limitations in mind, relevant management recommendations from the adult literature can still be extrapolated to the pediatric population.

Risk Management Pitfalls In Pediatric Patients With A Pneumothorax

1. “I performed a needle decompression to save the life of a patient with a tension pneumothorax. I thought I was a hero, but he subsequently decompensated.”
   Remember that needle decompression is an important and life-saving maneuver in the management of a tension pneumothorax. However, it is the first step, and according to current recommendations, it must be followed by the placement of a chest tube to allow for the evacuation of a presumed ongoing air leak.
    
2. “I made the call to transport a patient with an untreated large pneumothorax by air transport for definitive care at the medical center. He decompensated en route.”
   Pneumothoraces can expand by up to 30% at high altitude, and failure to account for this can result in dramatic miscalculation of the risk of developing an enlarging pneumothorax or even a tension pneumothorax.
    
3. “The father has complained that his son was in a lot of pain during the tube thoracostomy for management of a PSP by the surgery resident.”
   This is a markedly painful procedure. In hemodynamically stable patients, appropriate analgesia and/or sedation with opioids should be considered. These can be delivered by parenteral or intranasal routes. Generous local infiltration with lidocaine is advised.
    
4. “Now I’m panicking. I’ve attempted to place a chest tube for the management of a traumatic pneumothorax. Frank blood is spilling out of the tube. On x-ray, the tube is below the diaphragm.”
   Injury to the spleen or liver leading to hemoperitoneum or organ penetration of either of these hollow-viscus structures is a feared complication of tube thoracostomy. If suspected, leave the tube in place, clamp it to minimize blood loss, and obtain 3-dimensional imaging (typically a noncontrast CT scan of the chest, abdomen, and pelvis), and urgently consult surgery. These patients will often require an emergent exploratory laparotomy.
    
5. “I was called to evaluate a PSP in a patient who had become acutely hypoxic. Breath sounds were absent, and I suspected a tension pneumothorax. Because of significant respiratory distress I elected to intubate the patient prior to addressing the pneumothorax. I placed the endotracheal tube on the first pass, and the patient acutely decompensated when placed on the ventilator.”
   Large pneumothoraces can have impressive symptomatic presentations and hypoxia. The immediate treatment of symptomatic large pneumothoraces is the placement of an intercostal catheter. Endotracheal intubation can cause the rapid accumulation of intrathoracic air, converting a simple pneumothorax to tension physiology, if it is performed before the placement of an intercostal catheter.
    
6. “I accepted a patient for transfer with a large right-sided pneumothorax who had a chest tube placed at a small community hospital. A basic-life-support ambulance was sent for transport, and the patient began to complain of chest pain en route. A repeat chest x-ray on admission showed reaccumulation of the pneumothorax.”
   During transfer of a patient with a pneumothorax, it is important to make sure the transporting crew has the ability and equipment necessary to maintain the chest tube and prevent reaccumulation of the pneumothorax. It is critical to maintain care of the tube en route to avoid kinking or disconnection.
    
7. “I placed a small-bore intercostal catheter for the management of a large pneumothorax. Repeat imaging shows no change in the size of the pneumothorax, and the catheter appears to be along the lateral aspect of the chest wall.”
   The placement of an intercostal catheter or surgical chest tube is associated with a complication 2% to 10% of the time. Failing to penetrate the thoracic cavity and inserting the tube into a subcutaneous space is both ineffective and painful, and requires a second procedure. Another common complication is tube dislodgement because of failure of the clinician to adequately secure the tube with sutures and a sterile occlusive dressing.
    
8. “I misread the x-ray and placed the chest tube on the wrong side.”
   There are a few case reports in the literature, predominantly out of the neonatal literature, of thoracostomy tubes that were placed on the wrong side. Discussion of these cases identified a failure to mark the affected side with a radiopaque (R = right or L = left) marker on chest x-ray, and a confirmatory mark on the patient.¹⁴²
    
9. “A patient intubated in my ED for severe status asthmaticus was noted to require increased ventilator pressures. A STAT portable supine chest radiograph was obtained, which, surprisingly, did not reveal a pneumothorax.”
   Recall that supine chest radiographs have both poor sensitivity and specificity for detecting pneumothoraces. Consider alternative imaging modalities such as thoracic ultrasound or CT scan of the chest if you have suspicion for a pneumothorax.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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