Management of spontaneous pneumothorax in pediatric patients

Spontaneous pneumothorax is more common in males by approximately 3 to 1.

CT scan data fairly convincingly shows it is probably not beneficial with regard to changing treatment parameters or outcomes in spontaneous pneumothorax.

Chest tube management for spontaneous pneumothorax has approximately 50% failure rate across institutions.

Patients who receive chest tube, resolve, and go home have approximately 50% recurrence rate requiring subsequent intervention.

Patients who fail chest tube management in hospital and undergo VATS have 25-30% failure rate.

Patients who undergo immediate VATS have 10-15% failure rate.

The Society of Thoracic Surgery in adult patients recommends primary aspiration for spontaneous pneumothorax.

In most large studies for primary spontaneous pneumothorax, the mean age is around 20 to 22 years.

In a multi-institutional retrospective study of 81 patients across 3 institutions over 13 years, no patients presented with tension physiology.

Of 33 patients who underwent aspiration, 17 (approximately 50%) failed aspiration with recurrent pneumothorax within 6 hours.

In the Midwest Consortium prospective trial, 33 patients from 9 institutions over 2 years underwent initial aspiration with catheter left in place for 6 hours.

Of 12 patients who failed aspiration and received chest tube management, 83% subsequently failed chest tube management requiring VATS or experiencing recurrent pneumothorax.

Five patients who failed aspiration went directly to VATS, and none of those recurred.

Of 16 patients who passed aspiration and went home, 40% returned with recurrent pneumothorax.

The positive predictive value of aspiration for successful treatment is 83%, with negative predictive value of 56%.

In the three-institution retrospective study, patients who underwent pleurodesis had the same recurrence rate as those who underwent VATS without pleurodesis.

A large Chinese trial of 289 patients over 3 years, average age 22, randomized patients to wedge resection with or without mechanical pleurodesis and showed identical recurrence rates between groups.

There is no evidence that pleurodesis for initial operations for spontaneous pneumothorax decreases recurrence rates.

CT scans may be overcalling findings that are more common than historically expected and may not be clinically relevant, such as incidental blebs in patients who never develop pneumothorax.

For multiply recurrent pneumothorax after failed VATS, thoracoscopic pleurectomy of parietal pleura from apex to several ribs above diaphragm is an option, though it is arduous, bloody, and requires epidural analgesia with hospital stay of 7-10 days.

For small apical pneumothorax (2 centimeters) after pleurodesis with fixed lung, observation is preferred over intervention due to risk of injuring lung and creating larger air leak versus minimal physiologic impact of small residual space.