PEMP 0317 Pneumothorax In Pediatric Patients.pdf


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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 • www.ebmedicine.net

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.

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