PEMP 0317 Pneumothorax In Pediatric Patients.pdf

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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