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Pneumothorax In Pediatric
Patients: Management
Strategies To Improve Patient
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.

March 2017

Volume 14, Number 3
Matthew Harris, MD
Fellow in EMS and Disaster Medicine, Newark Beth Israel, Newark,
NJ, RWJ/Barnabas Health; Attending Physician, Division of
Pediatric Emergency Medicine, Cohen Children's Medical Center,
New Hyde Park, NY
Joshua Rocker, MD
Associate Chief, Division of Pediatric Emergency Medicine, Cohen
Children's Medical Center; Assistant Professor of Emergency
Medicine and Pediatrics, Hofstra Northwell School of Medicine,
New Hyde Park, NY
Peer Reviewers
Steven Choi, MD
Assistant Vice President, Montefiore Network Performance
Improvement; Director, Montefiore Institute for Performance
Improvement; Assistant Professor of Pediatrics, Albert Einstein
College of Medicine, Bronx, NY
Michelle K. Hughes, DO, FAAP
Children’s Hospital of the King's Daughters, Pediatric Emergency
Medicine Attending Physician, Associate Medical Director for
Trauma, Chair of Resuscitation Outcomes Committee, Assistant
Professor of Pediatrics, Eastern Virginia Medical School Department
of Pediatrics, Norfolk, VA
Steven Yung, MD
Medical Director of Pediatric Quality and Safety Services, Assistant
Professor, Pediatric Critical Care Medicine, Kravis Children’s
Hospital at Mount Sinai, New York, NY
Prior to beginning this activity, see “Physician CME Information”
on the back page.

Ilene Claudius, MD
Associate Professor, Department
of Emergency Medicine and
Pediatrics, USC Keck School of
Medicine, Los Angeles, CA

Alson S. Inaba, MD, FAAP
Garth Meckler, MD, MSHS
Pediatric Emergency Medicine
Associate Professor of Pediatrics,
Specialist, Kapiolani Medical Center
University of British Columbia;
for Women & Children; Associate
Division Head, Pediatric Emergency
Professor of Pediatrics, University
Medicine, BC Children's Hospital,
Vancouver, BC, Canada
Ari Cohen, MD
Medicine, Honolulu, HI
Chief of Pediatric Emergency Medicine
Joshua Nagler, MD, MHPEd
Services, Massachusetts General
Madeline Matar Joseph, MD, FACEP, Assistant Professor of Pediatrics,
Hospital; Instructor in Pediatrics,

Harvard Medical School; Fellowship
Associate Editor-in-Chief
Harvard Medical School, Boston, MA
Professor of Emergency Medicine
Director, Division of Emergency
and Pediatrics, Chief and Medical
Medicine, Boston Children’s
Vincent J. Wang, MD, MHA
Marianne Gausche-Hill, MD, FACEP,
Hospital, Boston, MA
Professor of Pediatrics, Keck
School of Medicine of the
Medical Director, Los Angeles
James Naprawa, MD
of Florida College of MedicineUniversity of Southern California;
County EMS Agency; Professor of
Attending Physician, Emergency
Jacksonville, Jacksonville, FL
Associate Division Head, Division
Clinical Medicine and Pediatrics,
Department USCF Benioff
of Emergency Medicine, Children's
David Geffen School of Medicine at Stephanie Kennebeck, MD
Children's Hospital, Oakland, CA
Hospital Los Angeles, Los Angeles,
UCLA, Los Angeles, CA
Associate Professor, University of
Joshua Rocker, MD
Cincinnati Department of Pediatrics,
Michael J. Gerardi, MD, FAAP,
Associate Chief, Division of
Cincinnati, OH
FACEP, President
Pediatric Emergency Medicine,
Editorial Board
Associate Professor of Emergency
Anupam Kharbanda, MD, MS
Cohen Children's Medical Center;
Jeffrey R. Avner, MD, FAAP
Medicine, Icahn School of Medicine Chief, Critical Care Services
Assistant Professor of Emergency
Professor of Pediatrics and Chief
at Mount Sinai; Director, Pediatric
Children's Hospitals and Clinics of
Medicine and Pediatrics, Hofstra
of Pediatric Emergency Medicine,
Emergency Medicine, Goryeb
Minnesota, Minneapolis, MN
Northwell School of Medicine, New
Albert Einstein College of Medicine,
Children's Hospital, Morristown
Hyde Park, NY
Tommy Y. Kim, MD, FAAP, FACEP
Children’s Hospital at Montefiore,
Medical Center, Morristown, NJ
Associate Professor of Pediatric
Steven Rogers, MD
Bronx, NY
Sandip Godambe, MD, PhD
Emergency Medicine, University of
Associate Professor, University of
Steven Bin, MD
Vice President, Quality & Patient
California Riverside School of Medicine,
Connecticut School of Medicine,
Associate Clinical Professor
Safety, Professor of Pediatrics and
Riverside Communtiy Hospital,
Attending Emergency Medicine
of Emergency Medicine and
Emergency Medicine, Attending
Department of Emergency Medicine,
Physician, Connecticut Children's
Pediatrics, UCSF School of
Physician, Children's Hospital of the
Riverside, CA
Medical Center, Hartford, CT
Medicine; Medical Director, UCSF
King's Daughters Health System,
Melissa Langhan, MD, MHS
Christopher Strother, MD
Benioff Children's Hospital, San
Norfolk, VA
Associate Professor of Pediatrics and Assistant Professor, Emergency
Francisco, CA
Ran D. Goldman, MD
Emergency Medicine; Fellowship
Medicine, Pediatrics, and Medical
Richard M. Cantor, MD, FAAP,
Professor, Department of Pediatrics,
Director, Director of Education,
Education; Director, Undergraduate
University of British Columbia;
Pediatric Emergency Medicine, Yale
and Emergency Department
Professor of Emergency Medicine
Research Director, Pediatric
University School of Medicine, New
Simulation; Icahn School of Medicine
and Pediatrics; Director, Pediatric
Emergency Medicine, BC Children's
Haven, CT
at Mount Sinai, New York, NY
Emergency Department; Medical
Hospital, Vancouver, BC, Canada
Robert Luten, MD
Director, Central New York Poison
Professor, Pediatrics and
Control Center, Golisano Children's
Emergency Medicine, University of
Hospital, Syracuse, NY
Florida, Jacksonville, FL
Adam E. Vella, MD, FAAP
Associate Professor of Emergency
Medicine, Pediatrics, and Medical
Education, Director Of Pediatric
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY

Click on the

David M. Walker, MD, FACEP, FAAP
Director, Pediatric Emergency
Medicine; Associate Director,
Department of Emergency Medicine,
New York-Presbyterian/Queens,
Flushing, NY

International Editor
Lara Zibners, MD, FAAP, FACEP
Honorary Consultant, Paediatric
Emergency Medicine, St. Mary's
Hospital Imperial College Trust,
London, UK; Nonclinical Instructor
of Emergency Medicine, Icahn
School of Medicine at Mount Sinai,
New York, NY

Pharmacology Editor
James Damilini, PharmD, MS, BCPS
Clinical Pharmacy Specialist,
Emergency Medicine, St. Joseph's
Hospital and Medical Center,
Phoenix, AZ

Quality Editor
Steven Choi, MD
Assistant Vice President, Montefiore
Network Performance Improvement;
Director, Montefiore Institute for
Performance Improvement; Assistant
Professor of Pediatrics, Albert
Einstein College of Medicine, Bronx,

CME Editor
Deborah R. Liu, MD
Assistant Professor of Pediatrics,
Keck School of Medicine of USC;
Division of Emergency Medicine,
Children's Hospital Los Angeles,
Los Angeles, CA

icon for a closer look at tables and figures.

Case Presentations

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.

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?

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.



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.
Copyright © 2017 EB Medicine. All rights reserved.

The exact epidemiology of primary spontaneous
pneumothorax (PSP) in children is unknown, as
patients with small pneumothoraces may never
present for medical attention. In the adult population, the incidence of PSP has been reported to
be 6 to 18 cases per 100,000 patients.5 Estimates
by Dotson et al, based on both census and national inpatient data, demonstrate an incidence of
PSP in children that ranges from 2.5 to 3.5 cases
per 100,000 patients. 6,7 In the literature, there
is significant predominance of pneumothorax
among men, ranging from 2:1 to 20:1. Among
the pediatric population, pneumothorax is much
more common in adolescent patients, with a


mean age of 15 to 17 years.6,8,9 Recurrence is more
common in the pediatric population than in their
adult counterparts.10

There is a positive family history for pneumothorax in as much as 10% of patients with PSP.
Conditions such as cystic fibrosis, asthma, and
other underlying pulmonary disorders predispose
patients to PSP. Pneumothorax is also slightly
more common in patients who smoke cigarettes or
marijuana.11,12 A report of chest pain or shortness
of breath with recent exercise or blunt chest trauma
sustained during sports activity should prompt
consideration of a pneumothorax.13

Neonatal pneumothorax is rarely encountered
in the ED. The incidence is thought to be approximately 1% to 2% of live births, though the incidence
increases to 4% to 6% in premature low-birth-weight

Traumatic pneumothorax can be the result
of both blunt and penetrating thoracic and/or
abdominal trauma. Nationally, 85% of thoracic
trauma is blunt, with reported mortality ranging
from 5% to 15%.17,18 The incidence of traumatic
pneumothorax in the setting of blunt trauma is
low, approximately 4%, compared to approximately 23% seen in the context of penetrating
thoracic trauma.19

Iatrogenic pneumothorax should be considered
in the patient presenting to the ED after a surgical procedure involving the thoracic cavity or after
procedures requiring endotracheal intubation with
mechanical ventilation. The placement of a central
venous catheter, rigid bronchoscopy, and drainage
of an empyema are included in the list of procedures
that may result in an iatrogenically induced pneumothorax.

The pleural space normally contains a small amount
of sterile fluid that provides lubrication to the visceral
and parietal pleurae, but it is devoid of air. The introduction of air into the pleural space is generally caused
by a defect in the pleura that results in a flow of air
from the area of higher pressure (alveoli) into the area
of lower pressure (intrathoracic cavity). Air will continue to flow until the pressures have equalized.

As air accumulates in the pleural space, it
will cause a number of mechanical problems. The
primary manifestation is collapse of the local lung
parenchyma that will become more extensive if
the communication or the accumulation of air is
significant. The collapsing lung, coupled with the
increased intrathoracic pressure, can cause obstruction of the venous and lymphatic structures in the
thoracic cavity and can move the contents of the
mediastinum toward the contralateral side. This can
result in tension physiology.
March 2017 •

Types Of Pneumothoraces
Table 1 provides a summary of the various types of
pneumothoraces and their characteristics and risk
Primary Spontaneous Pneumothorax
A PSP can occur in seemingly healthy individuals,
without underlying pathology. A common risk factor for PSP is a marfanoid body habitus, in which
patients are typically tall and thin. Smoking and illicit
drug use also have been shown to increase risk.20
There have been case reports of PSP in the setting of
recent marijuana12,21,22 or cocaine use.20,23 PSP has also
been linked to strenuous physical activity.24 Recurrence rates of PSP in adult patients have been reported to be 25% to 30%; however, in children who have
experienced a single pneumothorax, recurrence rates
may be close to 50%.10

Table 1. Types And Characteristics Of
Primary Spontaneous Pneumothorax
• Predominance in men
• Higher incidence in adolescents
• Higher incidence in patients with a tall, thin body habitus
• Recurrence rate: 25%-30% in adult patients, 50% in pediatric
Secondary Pneumothorax
• Related to underlying pathology (numerous genetic
• May require earlier definitive surgical intervention
Neonatal Pneumothorax
• Risk factors include prematurity, surfactant deficiency,
mechanical ventilation and sepsis, birth trauma, and low birth
• Uncommon in the emergency department
Traumatic Pneumothorax
• Can result from penetrating, blunt, or blast trauma to the thorax
and/or abdomen
• Often presents with concurrent injuries
• Significant morbidity and mortality
Open Pneumothorax
• Associated with an open chest wall injury
Occult Pneumothorax
• Small pneumothorax without clinical significance, typically seen in
Tension Pneumothorax
• Rapid accumulation of air within the thoracic cavity that leads
to a reduction in central venous return as well as a tamponade
effect on cardiac output
• Requires rapid life-saving interventions
Iatrogenic Pneumothorax
• Related to a number of common invasive procedures involving
the chest and neck
• Can result from barotrauma from mechanical ventilation
• May be the unintended side effect of resuscitative efforts

3 Copyright © 2017 EB Medicine. All rights reserved.

Secondary Pneumothorax
A secondary pneumothorax is the result of an
underlying disease process or trauma. In children,
a pneumothorax may be the presenting sign of
the pathology or the sequela of a known diagnosis, such as cystic fibrosis. Pneumothoraces can
also result from excessive coughing, as in severe
asthma exacerbation,6 pertussis,25 or pneumonia.
Additionally, numerous case reports and case
series have identified patients with a rare genetic
disorder with mutations in the folliculin gene,
known as Birt-Hogg-Dubé syndrome, who are at
higher risk of spontaneous pneumothorax.26-28
Secondary pneumothoraces typically occur later
in a patient’s life, due to disease progression, such
as in the case of patients with bronchopleural
fistula (aberrant connections between the bronchi
and pleural space that can be seen in the setting
of diseases such as cystic fibrosis or after thoracic
trauma). See Table 2 for a list of diseases and conditions that increase the risk of pneumothorax.

A rare type of secondary pneumothorax is
catamenial pneumothorax. Presenting typically
as monthly recurrent pneumothorax in a young
woman, it is believed to be an atypical presentation
of endometriosis.32 Endometrial tissue embeds on
the surface of the lung parenchyma. During menses,
bleeding causes local inflammation and necrosis,
leading to the development of an air leak and subsequent pneumothorax.

Neonatal Pneumothorax
In full-term infants, pneumothorax is likely related
to barotrauma during vaginal delivery. Most typically, these pneumothoraces become symptomatic
during the hospitalization period and are therefore
rarely encountered in the ED. Risk factors for neonatal pneumothorax include prematurity, surfactant
deficiency, low birth weight, out-of-hospital birth,
chronic lung disease, sepsis, and mechanical ventilation. Pneumothorax should remain on the differential diagnosis for the infant with an extramural
delivery who presents with respiratory distress.
Traumatic Pneumothorax
Pneumothorax is a common complication of both
blunt and penetrating trauma to the chest and/or
abdomen, and may also be seen in blast injuries. The
mechanism of traumatic pneumothorax is clearly
different than that of PSPs; therefore, evaluation for
concomitant injuries such as rib fracture, pulmonary
contusions, subcutaneous emphysema, and cardiac
injuries should be undertaken.33
Open Pneumothorax
An open pneumothorax is the result of penetrating
chest trauma that leaves a defect in the chest wall,
typically the result of a stab wound or missile penetration of the thorax. This will lead to an ongoing
air leak into the pleural space, and can quickly lead
to tension physiology.
Occult Pneumothorax
An occult pneumothorax is generally small and clinically silent on initial presentation. It is not seen on
initial chest radiography, but may be found incidentally on computed tomography (CT) scans intended
to evaluate other suspected injuries. There are limited
data in both the adult and pediatric literature regarding management of an occult pneumothorax diagnosed in the trauma patient. Obvious questions arise
regarding whether the pneumothorax will expand or
whether the presence of the pneumothorax indicates
that there may be a significant pulmonary injury. In
a large prospective observational study through the
Pediatric Emergency Care Applied Research Network
(PECARN) that enrolled 12,044 pediatric patients
who had suffered a blunt torso trauma, 8020 of these
children underwent chest radiography. A pneumothorax was identified in 372 patients (4.6%). Sixty percent
of these patients with a pneumothorax identified on
CT scans met the definition of occult pneumothorax
as described by the study authors.34 While 3-dimensional imaging is very sensitive for identifying occult
pneumothorax, the clinical relevance of the entity
remains questionable.

Table 2. Diseases And Conditions
That Increase The Risk Of Secondary
• Asthma
• Cystic fibrosis
• Alpha-1 antitrypsin deficiency29
• Congenital pulmonary airway malformation
• Congenital lobar emphysema
• Pneumonia
• Tuberculosis
• Pneumocystis
• Connective tissues disorders (ie, Ehlers-Danlos,30 Marfan
• Birt-Hogg-Dubé syndrome
• Catamenial pneumothorax
• Barotrauma (ie, mechanical ventilation, bag-valve mask)
• Mechanical ventilation
• Percutaneous lung biopsy
• Liver biopsy31
• Subclavian central line placement
• Internal jugular central line placement
• Thoracentesis
• Thoracic radiation

Copyright © 2017 EB Medicine. All rights reserved.

Tension Pneumothorax
A tension pneumothorax is a complication of either
primary or secondary pneumothorax, and it results in


the rapid accumulation of air in the pleural space due
to a 1-way ball-valve physiology. With each breath,
more air becomes trapped within the pleural space
and cannot escape. On physical examination, tracheal
deviation or jugular venous distension may be seen
as the air pushes the mediastinum to the contralateral
side and the superior vena cava becomes compressed.
A tension pneumothorax may rapidly precipitate
hemodynamic instability. A tension pneumothorax
should be on the differential in cases of asystolic arrest and pulseless electrical activity.

The acute decompensation often seen in tension physiology is likely the result of a cascade of
physiologic and biomechanical changes, mainly
ipsilateral lung collapse, chest wall overexpansion,
diaphragmatic depression, and mediastinal shift.
Circulatory collapse may result from the decrease in
venous return related to compression of the vasculature, as the mediastinum continues to shift. There is
a dramatic reduction in cardiac output secondary to
external compression or kinking of the great mediastinal vessels.35 Hypoxia and subsequently increased
pulmonary vascular resistance also contribute to
cardiovascular collapse.36
Iatrogenic Pneumothorax
Procedures involving the neck, chest, or abdomen
can lead to the introduction of air into the mediastinum or pleural space. Iatrogenic pneumothorax has
been described after tracheal intubation,37 subclavian and internal jugular cannulation,38 thoracentesis, lung39 and liver biopsy40, cardiopulmonary
resuscitation,41 rigid bronchoscopy for foreign body
retrieval,42-44 and endoscopic procedures.45 Pneumothorax related to barotrauma in mechanically
ventilated patients is also well-described.46

Differential Diagnosis
The clinical presentation of a PSP is highly variable.
Patients can present in varying degrees of acuity,
ranging from normal vital signs with unilateral chest
pain, to cardiorespiratory failure. As such, the differential diagnosis for PSP spans across numerous
organ systems. For chest pain and shortness of breath,
pulmonary causes are high on the differential diagnosis, and include asthma exacerbations, pneumonia,
bronchitis, foreign body retention, and pulmonary
embolism. Cardiac emergencies in otherwise-healthy
children are rare, but the pleurisy associated with
symptomatic pneumothorax is similar to the discomfort that can be seen in the setting of perimyocarditis,
and palpitations can mimic those seen with common
tachyarrhythmias, such as supraventricular tachycardia. Also on the differential diagnosis for patients
with chest discomfort and shortness of breath are
behavioral complaints such as anxiety and panic attacks. However, the most common cause of chest pain
March 2017 •

seen in the pediatric ED is musculoskeletal in origin,
namely, costochondritis.

Prehospital Care
The ability to recognize a pneumothorax and intervene in a safe and meaningful manner depends
on skill level (basic practice vs advanced life support), the presence of advanced practice providers
(physicians), and the mode and timing of transport
(ground vs air).

In the case of pneumothorax without tension
physiology, transport and oxygen supplementation
are the mainstays of care. For patients with evidence
of tension physiology (hypotension, tracheal deviation, hypoxia, jugular venous distension, or respiratory distress), interventions must be initiated as soon
as possible. Advanced Life Support (ALS) providers,
namely critical care emergency medical technicians
and paramedics, are trained to perform needle decompression for tension pneumothorax. The success
rates for needle decompression are variable, and are
related to the patient’s chest wall habitus, the presence of hematomas, and, often, the choice of catheter
of sufficient length to penetrate into the thoracic cavity.47,48 In the case of interfacility transport, definitive
care should be performed at the originating facility
prior to transport.

Air Transport

Patients with a suspected diagnosis of pneumothorax
may require air transport to the nearest pediatric facility for further evaluation and management. Occasionally, providers from helicopter emergency medical
services (EMS) will be the first medical contact for
these patients. The literature demonstrates that when
midlevel practitioners (as part of responding helicopter
EMS units) attempt field tube thoracostomy, the success rates are variable (50%-60%), and complications
have been reported.49-52

Patients who require medical transport by air
due to the severity of their illness or to avoid prolonged ground transport time are a particular challenge. Gas volume has been reported to expand up
to 35% at altitudes > 8000 feet (approximately 2440
meters). As such, a pneumothorax is a contraindication for transport by air unless the pneumothorax
has been fully evacuated, or there are no other
options for reaching definitive care.53 Rapid ascent
can lead to the evolution of tension physiology even
in pneumothoraces that were initially classified as
small.54,55 However, these concerns are dependent
on the air transport equipment and the altitude.
Most helicopters do not ascend > 1500 feet, and, at
that altitude, they pose no significant risk for the patient. Additionally, even though fixed-wing aircraft
fly much higher, their cabins are generally pressurized, so they also do not pose a significant risk.

5 Copyright © 2017 EB Medicine. All rights reserved.

Ground Transport

If the pneumothorax is secondary to trauma,
external signs of blunt or penetrating trauma may
be seen on the thorax, abdomen, or back. A seat belt
sign in a patient involved in a motor vehicle crash
is suggestive of significant force over the torso or
abdomen, and internal injury should be considered.

For a secondary pneumothorax that is a result of
an underlying pathological condition such as cystic
fibrosis, the same symptoms and physical examination
findings are seen as in a simple pneumothorax; however, the clinical picture may be complicated by the fact
that the patient has underlying pulmonary disease.

Interfacility ground transport for patients with a
known pneumothorax with a chest tube in place requires that the team ensures that all necessary equipment is available and functioning. Clinicians need to
pay attention to changes in the clinical status of the
patient that may correlate with equipment malfunction, obstruction, or displacement.

Positive-Pressure Ventilation

Patients requiring positive-pressure ventilation in
the setting of pneumothorax with either a bag-valve
mask or endotracheal tube present another set of
challenges to EMS providers and clinicians. Positivepressure ventilation can acutely worsen a pneumothorax, and may lead to the development of tension
physiology. This phenomenon must be recognized
quickly and immediate needle decompression
should be performed.

Early Intervention
The approach to a patient with a suspected pneumothorax is dependent on the etiology. All patients with
traumatic pneumothorax should be managed according to the Advanced Trauma Life Support (ATLS)
guidelines recommended by the American College of
Surgeons Committee on Trauma. If the pneumothorax is secondary to an underlying pulmonary disease,
the management of those patients needs to be addressed on a case-by-case basis.

Early interventions must include appropriate
airway management, administration of supplemental oxygen, and, if necessary, intravenous access.
Evaluation of the initial vital signs and a thorough
examination will help identify patients with symptomatic pneumothoraces who will require more
prompt interventions.

Emergency Department Evaluation
The presentation of a pneumothorax is highly variable
and depends primarily on the mechanism and the rate
and extent of air accumulation in the pleural space.
(See Table 3.) Small pneumothoraces may be asymptomatic or may present with only a cough.56 The most
common complaints are chest pain (100% of cases)
and dyspnea (41% of cases).57 Agitation, syncope, and
acute distress may also be presenting symptoms. For
children who are able to give a history, the chest pain
is typically described as sharp or stabbing, and worse
with respirations. Often, PSP occurs at rest or with
minimal exertion. A family history of recurrent pneumothoraces, poor wound healing, or aortic dissection
may be suggestive of underlying collagen vascular
disorders. Additionally, recognition of a marfanoid
habitus in the patient and possibly family members
may suggest Marfan syndrome, which predisposes the
patient to pneumothorax.

Table 3. Signs And Symptoms Of
Type of

Historical Features

Clinical Findings


• Chest pain that is
typically sharp or
• Shortness of
• Ipsilateral
shoulder pain
• Breathlessness
• Cough

• Diminished unilateral
breath sounds
• Vital signs and
respiratory effort
ranging from normal
to severely abnormal
• Tachypnea
• Tympany


Same features as
spontaneous, plus:
• Higher suspicion
in the setting
of penetrating
thoracic or
abdominal trauma
• Also seen in blunt
thoracic and
abdominal trauma

• Tracheal deviation to
the contralateral side
• Absent or diminished
aeration on the
ipsilateral side
• Jugular venous
• Shift of the apical
pulses to the
contralateral side
may be present56
• Hypotension

Physical Examination
Classic physical examination findings may include
ipsilateral decreased breath sounds; increased work
of breathing; and tympany, or hyperresonance on
percussion, if there is a large pneumothorax. Vital
signs may be normal, but can also demonstrate
tachypnea, hypoxia, tachycardia, and hypotension,
especially in tension physiology. Other findings of
tension pneumothorax include tracheal deviation,
jugular venous distension, decreased chest excursion, diminished heart sounds, and a shift of the
apical pulse to the contralateral side. In patients with
tension physiology, the degree of tachypnea and
tachycardia can be significant. Hypotension or cardiovascular collapse and, ultimately, cardiac arrest
can also result from a tension pneumothorax.
Copyright © 2017 EB Medicine. All rights reserved.



Diagnostic Studies
A pneumothorax can be suspected based on the
history and physical examination. Presurgical or
trauma tests may be appropriate in certain contexts;
however, there is no role for laboratory studies in
the diagnosis of a pneumothorax. While hypoxemia
may be found on a blood gas test, it is neither sensitive nor specific for pneumothorax. Although ancillary laboratory studies and electrocardiograms are
unlikely to assist in the diagnosis of pneumothorax,
they can be considered for determining an alternative diagnosis.

Imaging Studies
Confirmatory studies are not required for the patient
in distress; however, stable patients can undergo
imaging to confirm the presence of a pneumothorax.
(See Table 4.)
Chest Radiography
Historically, chest radiography has been the gold
standard for imaging of clinically important pneumothoraces. Radiographic evidence of a pneumothorax
includes the presence of: (1) the pleural line (representing the visceral pleura), which is not typically
visualized on chest radiography, and (2) the absence
of vascular markings beyond this demarcation. (See
Figure 1.) In a small pneumothorax, pleural air may

Table 4. Imaging Modalities For
Pneumothorax And Potential Findings
Diagnostic Study

Findings Suggestive of Pneumothorax

Chest x-ray for simple

• Visualization of the visceral pleural line
• Absence of visible vasculature in the
peripheral field
• Loss of ipsilateral lung volume
• Deep sulcus sign
• Fallen-lung sign70
• Double diaphragm sign71

Chest x-ray for tension

• Shift of the trachea and mediastinum to
the contralateral side
• Inversion of the ipsilateral
• Widening of the intercostal spaces

Thoracic ultrasoundc

Chest computed

• Blebs or other pulmonary abnormalities

Absence of normal lung sliding
Absence of comet-tail artifact
Presence of lung point(s)
Presence of lung pulse sign72
Deep sulcus sign


Can be upright, supine, or lateral decubitus position, but upright
inspiratory films are preferred.
Often performed in the supine position due to immobilization in the
setting of trauma.
Findings inconsistent with pneumothorax: presence of a "seashore
sign;" presence of lung sliding and comet-tail artifact.

March 2017 •

be notable at the apex of the affected side only on an
upright film. In the supine position, apical air collection may be difficult to identify. More commonly,
air can be seen in the subpulmonic and juxtacardiac
(anteromedial) areas and the lateral chest wall.58 Also
in the supine patient, an area of hyperlucency in a
depressed costophrenic angle, known as the deep
sulcus sign, will be seen and is nearly pathognomonic
of a pneumothorax.59-61 (See Figure 2, page 8.) This
may be the only radiographic evidence of an anterior
pneumothorax for a patient in the supine position.

There are few articles in the literature specifically evaluating the sensitivity and specificity of
chest radiography in children. Historically, upright
inspiratory chest radiographs have been obtained;
however, this may not be possible for patients in extremis or those immobilized in the setting of trauma.
The predictive value, sensitivity, and specificity of
plain films have been thoroughly evaluated in the
adult literature, and vary based upon patient position, as well as the point in the respiratory cycle
(inspiration vs expiration). A 2011 literature review
and meta-analysis by Zhang et al found a pooled
sensitivity of 0.52 and specificity of 1.00.62

The position of the patient during an x-ray has
been studied using cadaver models. It was demonstrated that pneumothoraces can be detected on
upright, supine, and lateral decubitus films, with
sensitivities of 59%, 37%, and 88%, respectively.63
In general, it is believed that expiratory films tend
to overestimate pneumothorax size, and inspiratory films tend to underestimate them.64 However,
using a panel of 3 radiologists, Seow et al reviewed
inspiratory and expiratory plain films of 85 patients
with known pneumothoraces and 93 controls. They
found that inspiratory and expiratory films had
comparable sensitivities (inspiratory mean, 83.1%;
expiratory mean, 83.9%) and specificities (inspira-

Figure 1. Pneumothorax On Chest

Absence of

Pleural line with
absence of
vasculature and
interstitial markings
Image courtesy of John Amodio, MD, FACR, Northwell School of
Medicine, Cohen Children's Medical Center, New Hyde Park, NY.

7 Copyright © 2017 EB Medicine. All rights reserved.

tory mean, 99.6%; expiratory mean, 99.7%). While
not explicitly stated, these were likely adult radiographic studies. Others have noted that expiratory
films may limit the reader’s ability to evaluate for
other pulmonary pathologies because pulmonary
expansion is limited.65

False positive results seen on chest radiographs
include the presence of skin folds in obese patients, folds of clothing, and misidentification of the
scapular border. (See Figure 3.) There are a number
of findings that help distinguish true pneumothoraces from false positives. Pneumothoraces have
a thin, distinct radiopaque line that represents the
visceral pleural edge, compared to a thicker, diffuse,
radiolucent band that diffuses into normal lung
parenchyma, as in the case of skin folds.66 In these
cases, a pleural line may appear to be visible, but the
fact that there are vascular markings lateral to them
indicate that it is not a pneumothorax.

artifacts of the pleural line. Comet tails are greysound artifacts on ultrasound that are present on
evaluation of normal lung parenchyma. They are
reflections of small calcifications on the pleural
lining, and are a type of reverberation artifact.
B-lines extend from the pleura to the bottom of the
screen and obliterate A-lines. When 4 or 5 B-lines
are present, they are known as "lung rockets." This
can be a normal finding, or they can identify an
underlying pathology such as interstitial edema or
pulmonary contusion.69

Findings Suggestive Of Pneumothorax

There are a number of findings on ultrasound that
may be suggestive of a pneumothorax. These include
the absence of lung sliding, comet tails, and B-lines, as
well as the presence of a lung point, lung pulse, or
deep sulcus sign.73 The absence of lung sliding is
suggestive, and nearly pathognomonic, of a pneumothorax or hemopneumothorax. In M-mode, the
absence of lung sliding produces so-called “stratosphere” or “barcode” signs, which also demonstrate a
lack of motion, with projections of a laminar, linear
pattern. (See Figure 5, page 9. ) Occasionally (and
less commonly in children), lung sliding may be
absent in the presence of large pulmonary bullae or
emphysema. In a review of 41 cases of pneumothoraces, comet tails were absent in 100% of patients.74
Combining the absence of lung sliding and comet
tails provides a sensitivity and negative predictive
value of 100% and a specificity of 96.5%.75

Point-Of-Care Ultrasound
Findings In Normal Lungs

Bedside or point-of-care ultrasound (POCUS) in
pediatric emergency medicine has recently
emerged as a useful tool in the evaluation of
patients with suspected pneumothorax.67 In a
healthy patient, ultrasound of the anterior aspects
of the lung should demonstrate a number of
characteristics, including lung sliding, A-lines, and
comet tails. (See Figure 4, page 9. ) Lung sliding
is the normal movement of the visceral pleura on
the parietal pleura that occurs in respiration. In the
absence of pathology, normal lung sliding produces
a granular appearance below the pleural line,
leading to the sonographic “seashore” sign in
M-mode.68 A-lines are horizontal reverberation

Figure 3. Scapula And Skin Fold Mimicking

Figure 2. Deep Sulcus Sign On Chest
Scapular line

Skin fold

Image courtesy of John Amodio, MD, FACR, Northwell School of
Medicine, Cohen Children's Medical Center, New Hyde Park, NY.

Copyright © 2017 EB Medicine. All rights reserved.

Image courtesy of John Amodio, MD, FACR, Northwell School of
Medicine, Cohen Children's Medical Center, New Hyde Park, NY.



On thoracic sonography, the presence of normal
lung findings on either side of an area where lung
sliding is absent (on either 2-D or M-mode) is
known as the lung point.76 The presence of a lung
point has been shown to have a sensitivity of 66%
and specificity of 100% in identifying patients
with a pneumothorax.77 There are complex cases
of pneumothorax where, due to the presence of
anatomic abnormalities, infection (empyema), or
blood, air can be loculated or trapped into distinct
compartments in the lateral or dorsal chest. In these
cases, one might identify a double lung point sign,
where alternating patterns of a sliding and nonsliding lung appear at opposite sides of the scan.78 This
double lung point sign has also been documented,
albeit rarely, in the case of spontaneous pneumothorax in adolescents, and may be suggestive of an
underlying pathology.79

Additionally, sonographers may be able to
visualize a rhythmic movement of the pleura that is
synchronous with the heartbeat, called the lung pulse
sign. The reverberations of the heart are well visualized through a poorly aerated, or collapsed, lung.80
The deep sulcus sign that can be evident on chest radiography can also be identified by lung ultrasound.
A study of 186 patients with blunt chest trauma
identified 56 cases of pneumothorax that were confirmed by chest CT. Of the 56 cases of pneumothorax, 55 cases were identified on pleural ultrasound
by demonstration of the deep sulcus sign.81

Figure 4. Normal Lung Findings On Thoracic

The 2012 International Liaison Committee on
Lung Ultrasound for International Consensus Conference on Lung Ultrasound provided high-quality
evidence to suggest that the presence of lung point(s),
coupled with the concurrent absence of lung sliding,
B-lines, and a lung pulse, are suggestive of pneumothorax.82 Again, these recommendations are based
primarily on literature and experience in the management of adult patients with pneumothoraces.

While there are no randomized controlled trials
comparing the use of POCUS to plain films in the
evaluation of children with suspected pneumothoraces, there is an evolving body of literature comparing these modalities in adult patients. A 2012
systematic review and meta-analysis found that
ultrasonography was 90.9% sensitive (95% confidence interval [CI], 86.5%-93.9%) and 98.2% specific
(95% CI, 97%-99%) compared to chest radiography
with a 50.2% sensitivity (95% CI, 43.5%-57%) and
99.4% specificity (95% CI, 98.3%-99.8%).83 Furthermore, Blaivas et al demonstrated higher sensitivity
for identification of pneumothorax by ultrasound
versus chest radiography in the supine patient, 98%
versus 75.5%, respectively, with similar specificity.84
Most studies comparing ultrasonography with chest
radiography utilize supine chest films, which have
both poor sensitivity and specificity; thus, the finding of better diagnostic accuracy by ultrasonography
may not be surprising.
Computed Tomography
CT of the chest remains the diagnostic gold standard
for identifying and quantifying pneumothoraces,
but it also exposes the patient to nontrivial doses of

Figure 5. Absence Of Lung Sliding
Suggestive Of Pneumothorax

Pleural line
Rib shadow

Comet tails




View A: The image was obtained using a L10-5 mHz linear transducer.
The image was taken with the probe positioned on the anterior chest
along the midclavicular line in the fourth intercostal space on the
sagittal plane, with the patient in the supine position.
View B: The image was obtained in the same location in the
transverse plane.
Images courtesy of Matthew Harris, MD, Cohen Children's Medical
Center, New Hyde Park, NY.

March 2017 •



View A: The “seashore” or “stratosphere” sign represents the presence
of lung sliding in seemingly healthy lung parenchyma.
View B: Note the laminar, linear pattern demonstrated in this “barcode”
sign, which is suggestive of the presence of a pneumothorax.
Images courtesy of Matthew Harris, MD, Cohen Children's Medical
Center, New Hyde Park, NY.

9 Copyright © 2017 EB Medicine. All rights reserved.

ionizing radiation and it has additional costs. Controversy exists as to whether or not to obtain a chest CT
scan in patients presenting with a first episode of PSP.
Obtaining a CT scan might be considered if chest radiography demonstrates large blebs (the presence and
number of blebs may have some utility in predicting
recurrence1,85) or to identify other structural abnormalities of the lung. While some pediatric surgeons
advocate for CT in patients who may require early
surgical intervention (those with tension pneumothorax at presentation, or those with suspected secondary pneumothoraces), the ACCP Delphi statement, a
statement with good consensus, does not recommend
chest CT for first-time pneumothorax.86

Some believe that obtaining a CT scan on all PSP
in children is important to reveal any pulmonary anatomical abnormalities, such as blebs or bullae, prior
to choosing a treatment type (catheter placement vs
operative exploration). The benefit of obtaining a CT
scan, even in patients who will undergo thorascopic
surgery, is controversial. In a retrospective study by
Tsou et al that looked at 297 patients, of whom 140
received a CT prior to thorascopic surgery, no differences were found in the length of the operation,
number of excised specimens, rate of complications,
or hospital length of stay.87 It appears true that CT
gives the clinician a better sense of the pleural and
pulmonary anatomy, but ultimately it appears that it
may not make any clinical difference in management.

A 2001 study by Noppen et al found that the Light
index accurately estimated the volume of a pneumothorax in 18 adult patients who underwent manual
aspiration with subsequent measurement of the removed air.89 While small in number, this study does
seem to bring some clinical validation of the Light
quantification method.
The Collins Method
In the supine position, the size of the thoracic cavity is relatively smaller than in the erect position.
Therefore, as Collins et al point out, a helical CT
may be helpful in quantifying the size of the pneumothorax. Similar to the Rhea average interpleural
distance method, measurements of the interpleural
distances are obtained at 3 anatomic locations and
multiplied by a correction factor to provide the
pneumothorax percentage.90
Comparison Of The Efficacy Of The Methods
The ability of these methods to quantify a pneumothorax is controversial. The Light index has been
criticized as underestimating the size of a pneumothorax when compared to measurements obtained
using the Collins method on CT.91,92 While all 3
methods of quantifying the size of a pneumothorax
have their own limitations, published works have
demonstrated that they are all equally effective in
detecting and predicting the size of a pneumothorax.93 However, none of these methods have been
validated in pediatric patients.

Size Quantification Of A Pneumothorax
In addition to the degree of symptomatic acuity, clinicians will often choose a management strategy based
on the estimated size or volume of a diagnosed pneumothorax. Based on the use of various imaging modalities, there are different formulas that help clinicians
and radiologists determine the size of a pneumothorax.

Comparison Of Diagnostic Studies For Quantifying
Pneumothorax Size
Though there is evidence that ultrasound may be
more sensitive than plain radiographs in the diagnosis of pneumothorax, debate exists over the utility of
ultrasound in quantifying the size of a pneumothorax.
In a study published in 2014, Volpicelli et al suggested
that ultrasound is superior to plain radiography in
quantifying the size of a pneumothorax, with a cut-off
of > 15% lung collapse suggestive of a large pneumothorax. The authors of that study suggest that evaluation for a lung point at the midaxillary line would
identify the anatomic boundary between small and
large pneumothoraces, and that the degree of laterality of the lung point corresponds with the increasing
size or classification of pneumothoraces.94

The Rhea Average Interpleural Distance Method
In a study published in 1982, Rhea et al measured
the interpleural distance at 3 locations: the maximal
apical distance, the interpleural distance midway
down the top half of the lung, and the interpleural
distance midway down the bottom half of the lung.
The summation of these 3 values, divided by 3 (to
give an average), provides the clinician with a calculated percentage of the pneumothorax.88
The Light Index
Another method used by radiologists to quantify
the size of a pneumothorax is to give a percentage
of lung volume, as dictated by the Light index. This
formula calculates the percentage of air leak as a
function of the lung diameter and hemithorax diameter on upright chest radiographs:

Management Based On Pneumothorax Size
Qualifying a pneumothorax as either large or small
based on the aforementioned methods is important
and will guide management. A large pneumothorax
is generally defined as being > 30% by volume. To
date, there are no uniformly accepted normative
values for thoracic volumes in children, and the size
definition of a pneumothorax by the 3 most common
clinical guidelines is based almost solely on adult

% lung volume involved = 100 – [(average lung
diameter3/average hemithorax diameter) x 100]
Copyright © 2017 EB Medicine. All rights reserved.



data. (See Table 5.) These guidelines do not measure
percentage, but rather comment grossly on the size
of the pneumothorax.

There are no consensus guidelines in the management of pneumothoraces in children. The following
information is extrapolated from adult management

Spontaneous Pneumothoraces
There are multiple approaches to the management of
spontaneous pneumothoraces, including discharge
with follow-up, observation and repeat x-ray, oxygen administration, needle aspiration, placement of
a small thoracostomy tube via the modified Seldinger technique, and placement of a large thoracostomy tube via the surgical method. The choice of
intervention has classically been dependent on the
etiology of the pneumothorax, the size of the pneumothorax, the acuity of presentation, and the extent
of the patient’s symptoms. The BTS, the ACCP, and
the BSP have developed classification systems to
guide clinicians in this decision algorithm. However,
it should be mentioned that significant discordance
between the BTS, ACCP, and BSP has led to a lack of
international consensus in management decisions.95

Small pneumothoraces that are managed with
observation only will reabsorb at approximately 1%
to 2% per day.96,97 Hypothetically, treatment with
100% oxygen hastens the resolution of pneumothoraces by increasing the gradient of nitrogen absorption
from the intrathoracic cavity, in a process referred
to as “nitrogen washout.“ Some small case reports
suggest rates of reabsorption closer to 4% to 5% with
oxygen therapy, with similar data found in animal
studies.98,99 However, the use of oxygen supplementation to hasten the resolution of a pneumothorax has
been met with mixed results in the literature.100-102
From the neonatal literature, Shaireen et al evaluated
the use of supplemental oxygen for neonatal intensive
care unit patients with spontaneous pneumothoraces
and found no significant benefit compared to those
treated on room air.103

The 2003 BTS guidelines recommend simple
aspiration as the first-line treatment for all PSPs that require intervention, ie, primarily large pneumothoraces

Table 5. Definitions Of Large Pneumothoraces
British Thoracic Society
≥ 2-cm gap between the pleural edge and the chest wall
Belgian Society of Pneumology
Complete dehiscence of the lung edge from the chest wall
American College of Chest Physicians
A distance of > 3 cm between the apical pleural edge and the
chest wall

March 2017 •

(with a pleural gap ≥ 2 cm) or smaller pneumothoraces
that are symptomatic.3 The pleural gap is defined as the
space between the chest wall and the pleural line on
plain film. The BSP agrees with the BTS recommendation for simple aspiration as the first-line treatment
of a large or symptomatic PSP. Prior to any invasive
intervention, clinicians should perform a “time-out” to
ensure that the patient has been appropriately identified and the affected side has been confirmed by physical examination and by imaging.

Patients who are to undergo manual aspiration should be administered supplemental oxygen
and then placed in a semirecumbent position, approximately 35° to 45° above supine, to promote the
accumulation of air at the apex of the affected side.
The landmark for manual aspiration is the second intercostal space, along the midclavicular line. Infiltration with 1% or 2% lidocaine can be instilled into this
area for topical anesthesia. A 16-gauge or 18-gauge
over-the-catheter needle is placed into the chest
wall above the third rib to avoid the neurovascular
bundle. A small amount of 0.9% sodium chloride
(normal saline) can be placed in the syringe. Aspiration is performed as the needle is advanced into the
chest wall. The presence of bubbling within the saline
suggests the successful placement within the pleural
space, though clinicians should be cautioned that the
aspiration of air can also be seen if the lung parenchyma itself has been violated. This maneuver can
be performed under sonographic guidance. Once the
catheter has been placed, it should be attached to a
3-way stopcock or Heimlich valve to create a system
that can be opened or closed easily during aspiration.
These valves allow for air to escape but do not allow
air to enter the pleural cavity, and are sometimes
referred to as flutter valves. Air is aspirated manually until no more air can be removed. Repeat chest
radiography is often used to confirm a reduction in
the size of the pneumothorax.104

In a case series of 91 adult patients with PSP,
Chan and Lam found a nearly 50% success rate with
simple aspiration and noted that the clinical and economic significance of avoiding chest tube placement
and subsequent hospitalization should be considered.105 Rates of success with simple aspiration have
been reported by others to be near 67%, with comparable rates of recurrence when compared to patients
treated with intercostal catheter placement.106,107 In
2002, Noppen et al performed a multicenter prospective randomized pilot study in Belgium evaluating
manual aspiration versus chest tube drainage for
first-episode PSP. The authors of this study found
that manual aspiration had comparable rates of
both immediate and 1-week success in managing pneumothoraces. Further, fewer patients who
underwent manual aspiration required hospitalization, and those who did had shorter lengths of stay
as compared to those with traditional intercostal
catheter placement.108 In a nonblinded but random11 Copyright © 2017 EB Medicine. All rights reserved.

Clinical Pathway For Management Of
Pediatric Patients With Pneumothorax
Patient presents with signs/symptoms
of pneumothorax



Did the patient experience trauma?


Complete ATLS primary survey


Tension physiology

Obtain chest x-ray and/or
ultrasound (Class I)

Tension physiology present?



Obtain upright chest x-ray
and/or ultrasound

immediate needle
(Class I)


Primary PTX
Small or
occult PTX

Large PTX

Clinically stable?


thoracostomy via
surgical method
(Class I)

Small PTX

Large PTX


consider O2,
repeat x-ray
(Class III)

Perform thoracostomy
via surgical method or
consider modified
Seldinger (as long
as no hemothorax is
identified) and admit
(Class I)

Obtain surgical
consultation if
specialist not
already present

• Observe, consider
O2, consider repeat
• Consider discharge,
if stable, with close
follow-up (Class I)

• Continue work-up
and treatment, as
• Admit if deemed

• Perform thoracostomy via modified
Seldinger technique (Class I) and admit
to surgical service
• Perform needle aspiration and observe
for several hours (Class II)

Abbreviations: ATLS, Advanced Trauma Life Support; O2, oxygen; PTX, pneumothorax.

regardless of size


If pain controlled and no recurrence
of symptoms, discharge with close
follow-up (Class II)

If pain not controlled, admit (Class II)

Class Of Evidence Definitions
Each action in the clinical pathways section of Pediatric Emergency Medicine Practice receives a score based on the following definitions.
Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy and effectiveness

Level of Evidence:
• One or more large prospective studies
are present (with rare exceptions)
• High-quality meta-analyses
• Study results consistently positive and

Class II
• Safe, acceptable
• Probably useful

Level of Evidence:
• Generally higher levels of evidence
• Nonrandomized or retrospective studies:
historic, cohort, or case control studies
• Less robust randomized controlled trials
• Results consistently positive

Class III
• May be acceptable
• Possibly useful
• Considered optional or alternative treatments

Level of Evidence:
• Generally lower or intermediate levels of
• Case series, animal studies,
consensus panels
• Occasionally positive results

• Continuing area of research
• No recommendations until further

Level of Evidence:
• Evidence not available
• Higher studies in progress
• Results inconsistent, contradictory
• Results not compelling

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2017 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Copyright © 2017 EB Medicine. All rights reserved.



ized controlled trial of 137 patients in Kuwait, Ayed
et al reached similar conclusions, and further noted
similar rates of recurrence at both 1 and 2 years postprocedure. Additionally, they found a lower analgesia requirement in patients who underwent manual
aspiration (34%) compared to those who underwent
tube thoracostomy (56%).86

A 2007 Cochrane review of 1239 articles identified only 1 randomized controlled trial of 60 adult
patients comparing simple needle aspiration to tube
thoracostomy. There was no statistically significant
difference in success rates (relative risk [RR], 0.93;
95% CI, 0.62-1.40) or early failure rates (RR, 1.12;
95% CI, 0.59-2.13) when comparing aspiration to
tube placement, but patients who underwent simple
aspiration did have lower rates of hospital admission (RR, 0.52; 95% CI, 0.36-0.75).109 In a review of 3
randomized controlled trials evaluating the differences between needle aspiration and tube thoracostomy, Zehtabchi and Rios found similar results;
needle aspiration was associated with the need for
less analgesia, lower pain scores, and shorter lengths
of stay in the inpatient setting.110

The BTS and BSP guidelines for the management of moderate-to-large pneumothoraces that are
refractory to initial aspiration and are concerning
for ongoing air leak recommend the placement of a
thoracostomy tube to allow for both acute and ongoing evacuation of intrathoracic air.3,4 The 2001 ACCP
Delphi Consensus Statement recommendations for
the management of pneumothoraces in the adult
population have some distinct disagreements with
the BTS and BSP guidelines. The ACCP does not recommend the drainage of pneumothoraces by simple
aspiration in any scenario. The ACCP recommends
that clinically stable patients with small pneumothoraces should undergo a period of observation in the
ED, which may include serial imaging to follow the
evolution of the pneumothorax.2 Most patients can be
discharged home with close clinical and radiographic
follow-up. Hospitalization should be considered for
patients with poor ability to follow up or in situations in which patients live a great distance from
definitive care. There is no commentary regarding
the use of supplemental oxygen. The ACCP recommends that patients with large pneumothoraces (≥ 3
cm apex-to-cupola distance) should be managed with
the placement of a thoracostomy tube. Initially, these
tubes can be connected to either a Heimlich valve or a
water seal, and suction can be applied if the lung fails
to re-expand.2 In a 2010 literature review, Fysh et al
found that small-bore catheters were equally effective
in evacuating pneumothoraces and were associated
with less discomfort.111 In one of just a few studies
comparing pigtail catheters and chest tube placement
in the pediatric ED, Dull and Fleischer found similar
efficacy, similar lengths of stay, and less need for analgesia in the pigtail group, though this finding was not
statistically significant.112
March 2017 •

Large Or Symptomatic Primary Spontaneous
Historically, the approach to managing patients with
large or symptomatic PSPs included the placement
of a chest tube via the surgical method. This method
requires a moderate incision in the lateral chest wall,
blunt dissection, and then forceful blunt penetration through the intercostal muscles and the pleura.
A larger thoracostomy tube is then placed in the
pleural space. The size of the chest tubes used with
the surgical method varies by the size of the patient.
(See Table 6.)

With the advent of the modified Seldinger technique and the recognition that a large catheter may
not be needed for the simple removal of air from
the pleural space, pigtail catheters or smaller-sized
thoracostomy tubes were introduced as an alternate
and effective means of draining pneumothoraces,
while also being less invasive.113,114 When using
the modified Seldinger technique, there is no need
for a moderate-sized incision, dissection, or blunt
penetration through the intercostal musculature, but
instead, a needle is placed in the pleural space and
a guidewire is used to maintain the course from the
skin into the pleural space. A dilator is used to expand the path so that, eventually, a small chest tube
can be inserted. The modified Seldinger technique
generally has a lower risk of complications, is less
painful, and leaves a much smaller scar. For more
details on catheter size, insertion, and complications,
see the November 2015 issue of Pediatric Emergency
Medicine Practice titled “Pediatric Chest Tubes And
Pigtails: An Evidence-Based Approach To The Management Of Pleural Space Diseases,” available at

Surgical Method
Prior to placing a chest tube or small-bore catheter, confirm the laterality of the pneumothorax on
imaging. Next, consider the use of local anesthesia
as well as analgesics and/or sedation. Patients can

Table 6. Chest Tube Selection For The
Surgical Method As Determined By Patient
Size (French)




















> 40




Reprinted from Pediatric Surgery, 7th ed, Puligandla P, Laberge J.
Infections and diseases of the lungs, pleura and mediastinum, pages
855-880, Copyright 2012, with permission from Elsevier.

13 Copyright © 2017 EB Medicine. All rights reserved.

be positioned in either a supine or semirecumbent
position. Surgical chest tubes are placed in the fourth
or fifth intercostal spaces, between the midaxillary
and anterior axillary lines. Appropriately identifying
landmarks will help ensure the proper placement of
the chest tube into the thoracic space, avoiding the
unintentional and often devastating introduction of
a chest tube into the abdominal cavity and injury
to the spleen or liver. Care should be taken to place
these catheters above the inferior rib, to avoid the
neurovascular bundle.

Once the landmarks have been identified, generous infiltration with either 1% or 2% lidocaine (with
a maximum of 5 mg/kg if used without epinephrine or 7 mg/kg in combination with epinephrine)
should be used to anesthetize the superficial skin,
periosteum of the local rib, and the deep tissue. A
1- to 2-cm incision is made in the intercostal space,
or on the skin overlying the inferior rib. A curved
dissecting Kelly clamp is then used to dissect down
to the intercostal muscles. The closed clamp should
be used to penetrate the parietal pleura. The index
finger should be used to confirm entry into the pleural space. With or without the use of a trochanter, the
thoracostomy tube is placed into the chest, guiding it
apically to best evacuate air.115 (See Figure 6.) After
placement, the thoracostomy tube is secured in place
with sutures. A dressing should be placed over the
insertion site (petroleum or dry gauze is sufficient),
which can be secured further with several more layers of gauze. Confirmation of placement should be
performed with chest radiographs.

placement, the tube should be connected directly
to a drainage system. Most commonly, chest tubes
and catheters are connected to a water seal, which
allows the passive movement of air out of the chest
but prohibits movement of air back into the pleural
space. Connecting the drain to direct suction is not
recommended; rather, the drain should be connected
to an underwater seal drainage system with a valve
(Heimlich) in place to allow for the unidirectional
flow of air. The ACCP Delphi Statement recommends that both pigtail catheters and surgical thoracostomy tubes should be connected to suction set to
20 cm H2O.2

Figure 6. The Surgical Method

Modified Seldinger Technique
A pigtail catheter or a small-sized thoracostomy
tube is typically placed using the modified Seldinger
technique. (See Figure 7.) Identify the same anatomic
landmarks as in the surgical method and infiltrate
appropriate anesthetic. Introduce a large-bore needle
into the skin. Aspirate slowly as the needle is advanced forward. Penetration into the pleural space
can be confirmed when air is easily aspirated into the
syringe. Again, a small amount of normal saline in the
syringe may be helpful, as the presence of bubbling
during aspiration is evidence of entry into the pleural
space. Once in the pleural space, place a J wire, and
remove the needle from the chest wall. Depending
on the gauge of the planned pigtail, a small incision
is often made with an 11-blade scalpel to facilitate
the introduction of a dilator, which is used to create a
pathway for the pigtail catheter. The pigtail catheter
should be secured to the skin with sutures, and confirmational imaging should be obtained.116

Blunt dissection of the intercostal muscles during surgical
thoracostomy tube placement. (Bloodless in photo; performed on a
Image courtesy of Kevin Ching, MD, Director, PEM Base Camp, Weill
Cornell Medical College, New York, NY.

Figure 7. The Modified Seldinger Technique

Connection To A Drainage System

Advancing chest tube over guidewire using the modified Seldinger
Image courtesy of Francesca Bullaro, Cohen Children's Medical
Center, New Hyde Park, NY.

Unconnected or unclamped chest tubes in spontaneously breathing patients allow air to reaccumulate
in the pleural space. To avoid this, after successful
Copyright © 2017 EB Medicine. All rights reserved.



Additional Surgical Interventions
Surgical intervention for PSP beyond the surgical
method is rare and is usually managed by a surgical
subspecialist. Indications include complete bilateral
pneumothoraces, persistent air leak after 72 hours of
therapy, patients with pneumothoraces that initially
present in tension, and patients at higher risk of
pneumothorax recurrence (mainly, patients with an
underlying disorder).117 Surgical approaches include
both open thoracotomy and, perhaps more commonly, video-assisted thorascopic surgery.

There is an evolving discussion in the literature
regarding the timing of surgery for spontaneous
pneumothoraces. Namely, whether or not surgical
intervention (bleb resection and either mechanical or
chemical pleurodesis) should occur after PSP recurrence. A small prospective study found that both
cost and morbidity increased in patients who underwent surgical repair after initial presentation of
PSP.118 In a retrospective review of pediatric patients
with PSP in Australia, O’Lone et al recommended
surgical intervention in patients with identified
anatomic abnormalities and in patients who failed to
have full resolution after 5 days of intercostal catheter placement.119

Complications Of Needle Thoracostomy,
Placement Of Intercostal Catheters, And
Tube Thoracostomy
The placement of a chest tube comes with risks.
These procedures are high-acuity, high-risk, and
low-frequency maneuvers. Significant morbidity
and mortality can be associated with these critical
care procedures.

Needle decompression must be performed with
care to avoid damage to the neurovascular bundle
located below the inferior aspect of the thoracic
ribs. Additionally, there are numerous case reports
of life-threatening complications, primarily injury
to the heart or thoracic vasculature during needle
decompression of correctly and incorrectly identified
tension pneumothoraces.120,121

The risks associated with the placement of a
surgical chest tube or pigtail catheter range from relatively common (eg, pain) to more clinically significant
(eg, infection, damage to the thoracic neurovascular
bundle, pulmonary laceration, damage to the heart
or thoracic vasculature, pneumothorax, and hepatic
or splenic perforation).122 These clinically significant
complications, though uncommon, are serious and often require invasive, corrective intervention.123 A case
series by Odita also documented phrenic nerve damage as a result of intercostal catheter placement.124 An
additional complication is falsely believing the tube is
in the pleural space when, in fact, it is external to the
thoracic cavity and, therefore, completely ineffective
at evacuating the pneumothorax.

Re-expansion pulmonary edema is a rare and
March 2017 •

poorly understood complication of tube thoracostomy and is believed to be the result of local inflammation at the alveolar-capillary level. There are
numerous case reports in the adult literature about
serious decompensation and mortality as a result of
re-expansion pulmonary edema.125 This phenomenon is poorly described in pediatric patients, though
articles in the anesthesia literature have attempted to
capture its description and management.126

Unstable patients may require endotracheal intubation. This may be unavoidable, especially in the
setting of trauma. Intubation will convert a patient
from a negative-pressure respiratory physiology to
a positive-pressure physiology. This may worsen a
pneumothorax by pushing air into the intrathoracic
space in the setting of an ongoing air leak. Therefore, if intubation is being considered, the chest tube
should be placed first or immediately after intubation, without significant delay.

Special Circumstances
Secondary Pneumothoraces
As mentioned previously, management of patients
with secondary pneumothoraces needs to be determined on a case-by-case basis, with the consultation
of the various subspecialists who are caring for the
child. Surgical interventions may be necessary in
the patient with extensive pulmonary bullae from
alpha-1 antitrypsin deficiency or parenchymal
pulmonary disease from cystic fibrosis. If the patient
is unstable or exhibiting tension physiology, decompressing the pneumothorax is of utmost importance
and, once stabilized, further interventions can be
discussed with the larger medical team.

Open Pneumothoraces
Open or “sucking” chest wounds are those that
violate the integrity of the chest wall, creating a
traumatic communication between the environmental atmosphere and the pleural space. These wounds
allow for rapid accumulation of air within the
pleural cavity. Open chest wounds lead to a cascade
of pathophysiologic problems. During inspiration,
air rapidly accumulates on the ipsilateral side, frequently leading to a tension state. During expiration,
as the intrathoracic pressure increases and eventually exceeds that of atmospheric pressure, mediastinal structures will shift toward the affected side.
As the pressure gradient across the mediastinum
drops, these structures will shift toward the contralateral side, a phenomenon described as mediastinal
flutter.127 In addition to the eventual placement of
a thoracostomy tube, immediate coverage of the
wound is indicated to create a 1-way “flutter valve”
that allows air to escape the thoracic cavity, but
not to re-enter. The application of multiple layers
of petrolatum gauze, in addition to normal sterile
15 Copyright © 2017 EB Medicine. All rights reserved.

dressings, can accomplish this goal if the dressings
are secured on 3 sides, allowing the fourth side to act
as a pop-off valve to allow for ongoing expulsion of
intrathoracic air. Patients with an open pneumothorax will ultimately require surgical intervention.127

fashion. Needle thoracostomy (also known as needle
decompression) is accomplished with the placement of a large-bore needle in the second intercostal
space, along the midclavicular line of the affected
side. The catheter should penetrate the chest wall
above the third rib to avoid injuring the neurovascular bundle that runs along the inferior aspect of the
thoracic ribs.129 In a study using 20 cadavers, Inaba
et al suggest that needle thoracostomy may be more
successful when placed in the fifth intercostal space
at the midaxillary line, although this technique has
not been widely adopted.130

Traditionally, the large-bore needles deployed
for this task in adults are 4.5 to 5 cm in length; however, numerous studies have shown that this length
may be too short in up to 30% of adult patients,
though clearly variation exists between patients in
various geographic locations and their body habitus.131-133 Some clinicians will attach a syringe of
saline to the needle during the procedure. Upon
entering the thoracic cavity, the clinician should see
bubbling within the syringe. There is an evolving
body of literature suggesting that, in many patients
(predominantly due to large body habitus), performing this life-saving procedure in the second intercostal space will not be successful. An alternative site,
such as the anterior axillary line at the fourth or fifth
intercostal space, may be up to 1.3 cm thinner in
adult patients.134

All patients who undergo needle decompression either in the prehospital setting or within the
ED must undergo tube thoracostomy if tension

Occult Pneumothoraces
Wilson et al conducted a retrospective review of 1881
adult blunt trauma patients in Nova Scotia, and identified 68 patients with occult pneumothoraces. Approximately half of this group underwent tube thoracostomy. Compared to patients who did not have a
chest tube placed, there was no statistical difference in
the Injury Severity Score between the 2 groups and no
pulmonary complications. The authors of that study
suggested that observation might be an appropriate
management approach.128 Further research is needed
to elucidate the best approach to occult pneumothoraces in both pediatric and adult populations.

Tension Pneumothoraces
A tension pneumothorax is an acute, life-threatening
event and must be promptly recognized and treated.
(See Figure 8.) Symptoms include absence of lung
sounds on the affected side, hyperresonance to percussion, and tracheal deviation, and may also include
hypotension and hypoxia.
Interventions And Complications
In accordance with the ATLS guidelines from the
American College of Surgeons, providers should
address a tension pneumothorax in a systematic

Figure 8. Evolving Tension Pneumothorax

Small apical pneumothorax noted with white arrow.

Expanding left pneumothorax with mediastinal shift. White arrow
indicates the pleural line of the pneumothorax.

Images courtesy of John Amodio, MD, FACR, Northwell School of Medicine, Cohen Children's Medical Center, New Hyde Park, NY.

Copyright © 2017 EB Medicine. All rights reserved.



pneumothorax is considered. Further, the ACCP
recommends that patients with tension physiology
at presentation should undergo primary surgical
intervention, as previously discussed.

Controversies And Cutting Edge
Prehospital Use Of Ultrasound To Identify
There is current literature (mainly from combat
experience) that promotes the use of ultrasound
to help clinicians identify pneumothorax in the
field.135,136 A study by Chin et al demonstrated that
EMS clinicians could be taught to detect critical
injuries, such as pneumothorax and pericardial effusion, after a brief educational intervention. Such
efforts will be crucial to the early identification and
appropriate management of patients with traumatic

Outpatient Management With Chest Tubes
In a 2014 retrospective review of prospectively gathered data from 132 adults with large spontaneous
pneumothoraces, Voisin et al were able to successfully manage 78% (103 of 132) of patients as outpatients
after the placement of a pigtail catheter connected to
a Heimlich valve. These 103 patients did not require
inpatient care, had resolution of symptoms and subsequent removal of the pigtail catheter by an average
of 3.4 days, and had low analgesia requirements.138

Telemedicine Guidance Of Chest Tube
Using mannequins, You et al showed that the performance of needle thoracostomy with the assistance
of online medical direction with live-feed video
increased the likelihood of success. Such video guidance may be beneficial for prehospital clinicians or
community providers who do not routinely perform
this procedure.139

Treating a patient with a pneumothorax is a team
effort that requires coordination from staff in emergency medicine, surgery, and possibly pulmonary
medicine or other subspecialties, based on the cause
of the pneumothorax. Disposition of patients with a
small PSP can be approached in one of two ways: (1)
In the appropriate clinical setting and with subspecialty consultation, discharge the patient home with
appropriate clinical and radiographic follow-up.
These patients should be given specific anticipatory
guidance about reasons to return to care, with any
suggestion of worsening pneumothorax. (2) Alternatively, clinicians might opt to admit the patient for
oxygen therapy and serial chest x-rays, especially if
the family does not live nearby or if there is a quesMarch 2017 •

tion of compliance with follow-up.

Disposition of patients with large spontaneous pneumothoraces may be managed in a number
of ways. There is evidence in the adult literature,
mostly from Europe, that simple aspiration and discharge home is a safe and acceptable alternative to
the placement of a chest tube. This view, advocated
by the BTS and BSP guidelines developed for adult
patients, is not currently accepted by the ACCP,
nor is it common practice in the United States.
Small-bore pigtail catheters placed via the modified Seldinger technique offer an additional level of
intervention, and, as previously discussed, studies
have shown that patients can be safely discharged
home with a catheter attached to a flutter Heimlich
valve. For many, however, the standard of care remains the placement of a chest tube with admission
to the hospital for further observation and evaluation. The need for an intensive care unit is generally
limited to the trauma patient who requires greater
monitoring and therapy secondary to other injuries.
Patients with a pneumothorax and a chest tube may
be admitted to an inpatient floor familiar with chest
tube management.

When discussing the various options with families, it is important to understand that the recurrence
of PSP has most often been reported as 30%; however, this number has been reported to be as high as
60% of patients, though those studies had a limited
number of patients.10

In the event that a patient who has undergone
chest tube placement requires definitive care at
another institution, there are a number of steps that
should be undertaken to ensure safe interfacility
transport. In addition to providing a detailed examination and description of interventions, all imaging
should accompany the patient to the receiving institution. It is crucial to ensure that the chest tube remains in place during transport, and that efforts are
made to prevent re-expansion of the pneumothorax.
Connecting the chest tube directly to wall suction
can lead to injury to the pulmonary parenchyma.
The chest tube can be either clamped or left to water
seal, as long as the chest drainage device is positioned below the patient on the transport stretcher.

Time- And Cost-Effective Strategies
A 1998 retrospective chart review by Gurley et al identified 44 patients who had intercostal catheters placed
after elective fine-needle biopsy of the lung. Of these
patients, 33 were observed as outpatients with connection to a Heimlich valve, 12 were observed in the ED,
and 1 was admitted for inpatient management. The
associated collective costs were $1689 for outpatient
management, $2403 for ED observation, and $3950 for
inpatient admission.140 A similar study by Campisi and
Voitk found a savings of $1150 per patient in a small
17 Copyright © 2017 EB Medicine. All rights reserved.

cohort of patients who were managed in the outpatient
setting with a Heimlich valve.141 Voisin et al found that
patients managed as outpatients after placement of a
pigtail catheter had a mean cost of $926 per patient,
compared to $4276 for patients managed traditionally with surgical tube thoracostomy and water-seal
drainage.138 The results from these studies suggest that,
in the appropriate clinical context, it may be safe and
cost-effective to manage patients with chest tubes in an
outpatient setting.

In their 2002 prospective, randomized pilot
study evaluating the success of manual aspiration versus chest tube drainage in a first episode of
PSP, Noppen et al found that patients treated with
manual aspiration (n = 27) had comparable success rates (both immediate and at 1 week), fewer
patients treated with manual aspiration required
hospitalization (52% vs 100%), and patients who
did require hospitalization had shorter lengths of

stay (3.4 ± 1.6 vs 4.5 ± 2.7 days) than patients with
chest tube drainage (n = 33).108 The results from this
study indicate that manual aspiration in the case of
first-episode PSP may be beneficial in comparison to
chest tube drainage.

Pneumothoraces in pediatric patients present in a
number of ways in the ED. PSPs are the most common presentation, with secondary pneumothoraces
seen most often in the setting of trauma. Symptomatology at presentation is dependent on the rapidity
of progression and the size of the pneumothorax.
The associated morbidity and risk of progression
of disease requires clinicians to promptly identify
and manage patients with a pneumothorax. There
is a dearth of well-designed studies in the pediatric
literature to help guide diagnostic and management

Risk Management Pitfalls In Pediatric Patients With A Pneumothorax
(Continued on page 19)

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.

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.

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

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.

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.

Copyright © 2017 EB Medicine. All rights reserved.



decisions. As a result, clinicians rely on the available
evidence in the adult literature and manage care
based upon well-established and evidence-based
algorithms proposed by the ACCP, BTS, and BSP.

Emergency clinicians should be thorough in
their evaluation of patients who may present with a
pneumothorax, given the potentially life-threatening
nature of the process. There is strong evidence
that upright films, either inspiratory or expiratory,
should be sufficient in identifying patients with a
pneumothorax, with similar sensitivity and specificity. Thoracic ultrasound provides an effective
approach to aid clinicians, especially in the patient
who is required to remain supine. Management will
be based primarily on patient presentation, appropriate follow-up, resource availability, and provider
proficiency in the performance of these high-risk,
low-frequency procedures. In accordance with the
ACCP guidelines, it seems reasonable that patients

with small pneumothoraces who have minimal
symptoms could undergo a period of observation in
the ED with serial imaging, and could likely be discharged home with close clinical and radiographic
follow-up. An alternative (and perhaps more conservative) option would be admission for supplemental
oxygen administration, observation, and appropriate
subspecialty consultation.

Hemodynamically stable patients with large
pneumothoraces require an intervention to prevent
progression of the pneumothorax and to relieve
symptoms. While there is evidence to suggest that
simple aspiration is more cost-effective and may
be equivalent to the placement of a chest tube, it
has not become normative in the United States or
in pediatrics, nor is it the recommendation of the
ACCP. While traditional training has supported the
placement of a chest tube via the surgical method,
there is ample evidence that a small-bore intercostal

Risk Management Pitfalls In Pediatric Patients With A Pneumothorax
(Continued from page 18)

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
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.

March 2017 •

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

19 Copyright © 2017 EB Medicine. All rights reserved.

catheter placed by an emergency clinician via the
modified Seldinger technique is equally successful in
evacuating a pneumothorax, and may be associated
with fewer complications, shorter hospital lengths
of stay (if admitted), and less analgesia use. Surgical thoracostomy tube continues to be an alternative
method, especially in the patient in extremis and in
patients presenting with traumatic pneumothoraces
or tension physiology.

large PSP is to place a pigtail catheter, which you did via
the modified Seldinger technique. The patient was then
admitted to the surgical service.

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.

Case Conclusions
You followed ATLS guidelines for hypotension in the
setting of trauma and immediately began your primary
survey of the 12-year-old boy. The airway appeared to
be intact, and your assessment of his breathing revealed
decreased air entry on the right side, which was the side
of the wound. You quickly thought of your differential:
pneumothorax, hemothorax, or a combination of both.
The hypotension and tachycardia could represent either
hemorrhagic shock from a vascular injury or, potentially,
a tension pneumothorax from a direct penetrating lung
injury. You determined that the patient was too unstable
to await imaging and you picked up an 18-gauge needle
and syringe. As you performed a needle decompression in
the midclavicular line at the second intercostal space, you
simultaneously instructed a nurse to place the patient on
a nonrebreather mask. Members of your team administered fluid boluses in the 2 large-bore IV lines. Air gushed
out of the chest as the needle penetrated into the thoracic
cavity. The patient’s vital signs gradually improved,
and the patient looked dramatically relieved and more
comfortable. You obtained a chest x-ray that revealed a
new small pneumothorax. You knew you needed to put
in a chest tube following the needle decompression. This
being a traumatic injury, you decided to place a large-bore
catheter instead of a pigtail catheter. Once placed, you observed both humidity and some blood in the catheter. You
were correct to think of both a hemothorax and a pneumothorax. Based on the amount of blood retrieved (75 mL),
you now understand that his change in vital signs was
due to the tension pneumothorax, because it appeared that
the vascular injury was minor. The patient was admitted
to the trauma service.

You were concerned that the 15-year-old boy with
sudden chest pain had a primary spontaneous pneumothorax. The patient was tall and thin and, even though
his vital signs were normal, the diminished breath
sounds on the right, with no fever and no history of
coughing, were concerning to you. You obtained an
upright inspiratory film. While you were waiting for
the chest x-ray to be read, you decided to obtain images
via ultrasound. On ultrasound, you noted the absence
of lung sliding and comet tails, but you did see the
lung pulse sign. When you switched from D-mode to
M-mode, you were unable to see the seashore sign. The
radiologist arrived and confirmed that there was a 30%
pneumothorax. The standard in your institution for a
Copyright © 2017 EB Medicine. All rights reserved.

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1. A common etiology for a secondary pneumothorax is:
a. Sinusitis
b. Cerebral palsy
c. Scoliosis
d. Cystic fibrosis
2. What is the most telling sign that your patient
has a tension pneumothorax?
a. Oxygen saturation of 93%
b. Decreased breath sounds on 1 side
c. The patient is in significant pain
d. Tracheal deviation
3. Tension pneumothorax physiology causes
dramatic changes in the patient’s vital signs as
a result of:
a. Hypoxia
b. Hypoventilation
c. Kinking of essential mediastinal structures
d. Alveolar air trapping
4. As the on-duty physician of the regional
transport medical command center, you get a
call from a basic-life-support team that they are
picking up a 16-year-old boy with no previous
medical problems who began having suddenonset chest pain 6 hours ago. Upon arrival, the
patient is more uncomfortable and in mild
distress. His vital signs are normal, and on
physical examination, he has decreased breath
sounds on the right side. His trachea is midline. What is your advice to the team?

March 2017 •

a. Give albuterol via nebulizer.
b. Place the patient on a 100% nonrebreather
mask and transport him to the closest hospital.
c. Needle-decompress the right chest and
drive, lights and sirens, to the nearest
hospital, regardless of their pediatric
capability (because he is 16 years old).
d. Transfer the patient to the regional pediatric
center (100 miles away), since the patient is
stable but requires specialized pediatric care.
5. A thin, 14-year-old boy is brought in with sudden onset of chest pain and gradual onset of
respiratory distress. He made a diving catch in
an Ultimate Frisbee game earlier today. Due to
neck pain, EMS placed him in a cervical collar.
A supine chest radiograph was obtained by
the resident, which was read as normal by the
radiology resident. What is the best next action
to take?
a. Obtain a CT scan of the chest, abdomen, and
b. Obtain upright inspiratory chest films.
c. Obtain a 12-lead electrocardiogram.
d. Consider obtaining a D-dimer to screen for a
pulmonary embolism.
6. What is the deep sulcus sign on an x-ray?
a. An area of hyperlucency in a depressed
costophrenic angle
b. A linear groove extending laterally from the
c. A deep, thick line seen in the lung on the
contralateral side
d. A depression in the trachea in a patient with
a tension pneumothorax
7. Which of the following EXCLUDES a pneumothorax on ultrasound?
a. The presence of lung sliding
b. The “stratosphere” sign
c. The presence of B-lines
d. The presence of A-lines
8. A 16-year-old girl with mild chest discomfort
is found to have a small left apical pneumothorax. Her respiratory rate is 12 breaths/min
and her oxygen saturation is 100% on room
air. Appropriate management of this primary
spontaneous pneumothorax may include:
a. Needle decompression in the second 

intercostal space, midclavicular line
b. Insertion of a small-bore catheter into the
fifth intercostal space via modified Seldinger
c. Discharge home with close follow-up
d. Immediate surgical consultation for videoassisted thorascopic procedure
25 Copyright © 2017 EB Medicine. All rights reserved.

9. A 5-year-old patient who was born prematurely is admitted for an asthma exacerbation
that is challenging to control. The patient is
intubated for poor oxygenation, and you are
called into the room 4 hours later because the
patient’s oxygen saturation suddenly dropped
and the patient is having significant respiratory distress. On examination, the patient has
decreased breath sounds on the left side and
tracheal deviation to the right. The best next
step is to:
a. Call surgery immediately
b. Increase oxygen to 100% and re-evaluate in
5 minutes
c. Obtain an arterial blood gas test
d. Perform needle decompression on the left
side and follow it immediately with a leftsided chest tube

10. An 18-year-old boy with blunt trauma to the
chest is found to have a large right-sided
pneumothorax. Surgical tube thoracostomy is
performed in the trauma bay, releasing air and
a small volume of blood. When the patient is
stabilized, he is transferred into an observation room in your ED, and he soon begins to
complain of return of right-sided chest pain
and shortness of breath. A repeat STAT portable chest x-ray shows a reaccumulation of the
pneumothorax. After placing the patient on
100% oxygen, the best next step would be:
a. Needle decompression
b. Placement of a second surgical chest tube
c. CT scan of the chest to evaluate for a
bronchial injury
d. Ensure that the thoracostomy tube is
connected appropriately to water seal and
that all clamps are removed

Download Your Pediatric Pathways Now!
The algorithms included in Pediatric Pathways: Evidence-Based Algorithms
To Improve Quality Of Care, Volume II provides you with a quick reference
and step-by-step guide to common problems you face daily when managing
pediatric patients. In addition, this compilation includes management
pearls, an overview of guidelines, as well as disposition recommendations
for each of the topics covered.
Included with this pathway compilation:
1. 12 pages of evidence-based content
2. 6 clinical pathways
3. Information to help you keep up with current guidelines and best
4. Treatment recommendations to help you determine the critical actions
required when caring for pediatric patients
5. A quick reference to management of blunt chest trauma, urinary tract
infections, neonatal vomiting, skin and soft-tissue infections, and
inhaled foreign bodies


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Ponte Vedra Beach, Florida
Jointly Organized by:

Icahn School of Medicine at Mount Sinai
University of Florida College of Medicine Jacksonville
Mayo Clinic School of Medicine
Harvard Medical School
University of Colorado School of Medicine
EB Medicine

Pediatrics Day


FRIDAY, JUNE 23, 2017

Spend the afternoon with a team of pediatric resuscitation experts improving your skills in taking care of critically ill children. This
session is a fully interactive, simulation-based, hands-on workshop covering pediatric airways and other critical illnesses unique to
your pediatric patients. Learn the latest in pediatric resuscitation, test your skills, and have a great afternoon learning! Enroll early
and you can even shape the curriculum! Have a topic you want to review? A procedure you want to practice? Enroll by April 1st and
you can email the course director and we’ll try to work your request into our simulations.
• The Crashing Neonate
• Case Studies in Pediatric Fever
• Pediatric Ultrasound: What is the Standard?
• The Ifs, Whys, and Whens of Vomiting in Children
• Derm 101: Simple Rashes, Complex Decisions
• Gynecologic Emergencies
• Sepsis Update
• Transplant Emergencies
• Gastroenteritis: When and How to Treat
• Can’t-Miss Orthopedic Conditions

• Pediatric Resuscitation Simulation
(Limited to 20 participants)


To register,
call 866-924-7929 or 503-635-4761 or
This live activity has been planned and implemented in accordance with the Essentials and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the
joint sponsorship of EB Medicine and the Physicians Consortium. EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. EB Medicine designates this educational activity for a maximum of 5 AMA PRA Category 1 Credits™ for the main course and a maximum of 3 AMA PRA Category 1 Credits™ for the Pediatric Resuscitation
Workshop. Participants should only claim the credit hours commensurate with the time that they actually spent participating in the educational activity. Faculty Disclosure: It is the policy
of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the
relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity are asked to complete a full disclosure statement. This information will be
presented as part of the course materials at the conference. Commercial Support: As of the time of this advertisement, this activity has received no commercial support. A full commercial
support disclosure statement will be presented as part of the course materials at the conference.

March 2017 •

27 Copyright © 2017 EB Medicine. All rights reserved.


A Quick-Read

Review Of Key

Points & Clinic

al Pearl

s, July 2016
Pediatric Severe
Traumatic Brain
An Evidence-Ba
sed Review

Cervical artery
dissections involv
vertebral arterie
e the carotid or
s. An intimal
tear creates a
dolumen with
Cervical artery
later lead to vessel ural hematoma, which
dissections can
occlusion, throm
with minor traum
tion, embolus,
a or spontaneous occur
pseudoaneurysm, bus formaly.
Cervical artery
or rupture.
dissections from
Maintain a high
caused by direct
blunt trauma
index of suspic
blow to the neck,
artery dissections
ion of
sion or contra
hyperextenin patients presen cervical
lateral rotatio
risk factors or
ting with
n, intraoral traum
or skull-base
any concerning
occur spontaneous es. However, they can also
average, sympt
trauma. On
Early administratio
oms occur 2 to
n of antiplatelet
3 days after the
traumatic event.
significantly reduce agents or
• Cervical artery
stroke in cervica
s the risk of
dissections may
headache, facial
present with
pain, or neck
pain and may
associated with
Cervical artery
dissection is not
symptoms, dysgeu
sia, pulsatile
cation for throm
a contrainditinnitu
bolytics for ischem
Risk factors includ s, or cervical radiculopath
ic stroke.
vascular abnorm e connective tissue diseas
e and
• Cervical artery
• Liberal screen alities.
dissection is not
ing criteria are
for thrombolytic
a contraindica
High-risk findin
s for ischemic
stroke. Patien
acute strokes
cal deficits, Glasgo include lateralizing neurol
ts with
can receive throm
Coma Scale score
when cervical
s safely even
cal hematoma,
artery dissect
< 8, cervibruit, thrill or
ion is suspected.
crepitus, anisoc
Horner syndro
telet agents and
me, cervical spine
tion should be
anticoagulaFort type II or
fracture, and
delayed for 24

• Though digital
ts diagnosed
with a cervica
subtraction angiog
tion should be
l artery dissec
gold standard
raphy is the
admitted and
for diagnosis
closely monito
Follow-up imagin
of cervical artery
sections, compu
g is needed to
progression in
assess disease
an accepted choice tomographic angiography
7 to 10 days.
• Due to the
and 95% to 100% , with 98% to 100% sensitivity
lack of data, blood
specificity while
pressure manag
ment targets
risks and delays
having fewer
are up to indivi
ecompared to angiog
ers based
c patient charac
netic resonance
raphy. Magteristics.
is also an alterna
but is not sensiti
Issue Author
ve for vertebral
• Early admin
artery dissect
Rhonda Cadena
with antiplatelet n of antithrombotic therap
Assistant Professo , MD
agents (eg, aspirin
r, Departments
Emergency Medicine
of Neurology,
lants (eg, hepari
, University of
n) has been shown ) or anticoaguand
North Carolina,
Points & Pearls
reduce the risk
Chapel Hill, NC
of stroke in cervica to significantly
tions. There is
l artery dissecJeremy Kim,
no clear benefi
Department of
t of one agent
another, but many
Emergency Medicine
Sinai, New York,
prefer heparin
, Icahn School
of Medicine at
an acute throm
in the setting
contraindications or vessel occlusion. If there
to antithrombot
vascular treatm
ic therapy, endoent should be
July 2016 • Emerg
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0;68(2):4 1cb43da
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S, Gro
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:699(87.5% s (25%), and for Surger
cular injug. 2002;235(5)
WNL.0b Ray CE, Jr,
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blunt cere raphy. Ann study; 171 pati
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EB Medicine is proud to announce a brand-new
benefit to your Pediatric Emergency Medicine
Practice subscription: Points & Pearls!
Each Points & Pearls digest will include key points
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Physician CME Information
Date of Original Release: March 1, 2017. Date of most recent review: February 15, 2017.
Termination date: March 1, 2020.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing
Medical Education (ACCME) to provide continuing medical education for physicians.
This activity has been planned and implemented in accordance with the accreditation
requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4
AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate
with the extent of their participation in the activity.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the
American College of Emergency Physicians for 48 hours of ACEP Category I credit per
annual subscription.
AAP Accreditation: This continuing medical education activity has been reviewed by the
American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per
year. These credits can be applied toward the AAP CME/CPD Award available to Fellows
and Candidate Fellows of the American Academy of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48
American Osteopathic Association Category 2A or 2B credit hours per year.
Needs Assessment: The need for this educational activity was determined by a survey
of medical staff, including the editorial board of this publication; review of morbidity and
mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities
for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians,
physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical
decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose
and treat the most critical ED presentations; and (3) describe the most common
medicolegal pitfalls for each topic covered.
CME Objectives: Upon completion of this article, you should be able to: (1) Describe
the types of pneumothoraces, risk factors, and clinical presentations; (2) identify
high-risk situations, including traumatic pneumothoraces, tension physiology,
and pneumothoraces that require early surgical intervention; (3) describe the
diagnostic evaluation and therapeutic approach to patients with spontaneous and
traumatic pneumothoraces, and (4) discuss the controversies in the management of
Discussion of Investigational Information: As part of the journal, faculty may be
presenting investigational information about pharmaceutical products that is outside
Food and Drug Administration approved labeling. Information presented as part of this
activity is intended solely as continuing medical education and is not intended to promote
off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance,
independence, transparency, and scientific rigor in all CME-sponsored educational activities.
All faculty participating in the planning or implementation of a sponsored activity are expected
to disclose to the audience any relevant financial relationships and to assist in resolving
any conflict of interest that may arise from the relationship. Presenters must also make a
meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs
or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty
for this CME activity were asked to complete a full disclosure statement. The information
received is as follows: Dr. Harris, Dr. Rocker, Dr. Choi, Dr. Hughes, Dr. Yung, Dr. Vella,
Dr. Wang, and their related parties report no significant financial interest or other
relationship with the manufacturer(s) of any commercial product(s) discussed in this
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Earning Credit: Two Convenient Methods: (1) Go online to
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