1. Spontaneous pneumothorax in the pediatric population

2. Air in the pleural cavity
Lung is partially or completely collapsed
Traumatic – usually due to a traumatic defect in the chest wall
Spontaneous – unclear etiology – perhaps due to rupture of apical blebs

3. Treatment: Observation O2 supplementation Chest tube decompression
VATS blebectomy and pleuredesis

4. Incidence – about 0.001%
Recurrence – 50-60%

5. What Factors Predict Recurrence after an Initial Episode of Primary Spontaneous Pneumothorax in Children?
Choi et al, Ann Thorac Cardiovasc Surg. 2013

6. Retrospective review
Inclusion: patients 18yo or younger with primary spontaneous pneumothorax
Exclusion: surgical intervention, loss to f/u, immediate transfer to outside facility, refusal of CT.

7. 249 cases reviewed
114 included in the analysis
Not a very large study, but much better than most for this topic

10. Rapid growth in adolescence, leading to relatively faster thoracic cavity expansion compared to lung tissue growth?
Unclear cause for the above difference in BMI and age.

12. Definitions of ptx size for that institution (by CXR):
Minimal - <1cm
Small – 1-2cm
Moderate - >2cm, but less than the width of the remaining lung
Large – more than the width of the lung
Complete – lung tissue in hilum only

13. Minimall and small (asymptomatic): supplemental O2
Symptomatic and/or moderate and larger: chest tube drainage
Air leak 5-7 days – VATS blebectomy and pleuredesis.

14. What about O2 therapy?
Oxygen Therapy for Spontaneous Pneumothorax. Northfield. BMJ, 1971
22 patients with pneumothorax: 12 received rest/observation. 10 had 100% O2 via mask every other day
Area of ptx on XR was calculated every day.
Tiny study and unclear methods

16. Resolution of Experimental Pneumothorax in Rabbits by Graded Oxygen Therapy. England et al, J Trauma, 1998.
40 rabbits with surgically created ptx in 4 groups: RA, 30% O2, 40% O2, 50% O2.
This was done by injecting air into pleural space

17. Figure 1
Resolution of Experimental Pneumothorax in Rabbits by Graded Oxygen Therapy.
England, Gregory; Hill, Ronald; Timberlake, Gregory; Harrah, Jason; Hill, Jeffrey; Shahan, Yvonne; Billie, Michael
Journal of Trauma-Injury Infection & Critical Care. 45(2): , August 1998.
Figure 1 . Mean hours to resolution of experimental pneumothoraces in one rabbit in each group of rabbits: room air (21%) and 30, 40, and 50% FiO2. Brackets represent SEM.
© Williams & Wilkins All Rights Reserved. Published by Lippincott Williams & Wilkins, Inc. 2

18. Supplemental oxygen improves resolution of injury-induced pneumothorax
Supplemental oxygen improves resolution of injury-induced pneumothorax. Zierold et al, J Pediatric Surgery, 2000.
27 rabbits with surgically created ptx. This time, this was done with thoracoscopically-guided puncture of visceral pleura.
Rabbits divided into 3 groups: RA, 40% O2, 60% O2.

19. Fig. 1 Time for pneumothorax resolution in the RA, 40%, and 60% groups (data reported as mean ± SD). P <.05 1-way ANOVA RA versus 40%, RA versus 60%, and 40% versus 60%..

20. Limited studies on O2 therapy.
Unclear mechanism – increased partial pressure of O2 in pleural cavity, leading to faster relative absorption?

22. Presence of radiographic blebs/bullae corresponded to increased risk of recurrence
Seems to be in line with blebs/bullae being origins of spontaneous pneumothoraces
86% of patients with bullae on CXR had a recurrence!

23. Dystrophic severity score?
Bleb (<1cm) vs bulla (>1cm): 1 or 2 points
One vs many: 1 or 2 points
Unilateral vs bilateral: 1 or 2 points

26. Size of the pneumothorax was not significantly correlated with the chance of recurrence!

28. Blebs/bullae are correlated with a higher recurrence rate

30. No relation between blebs/bullae and contralateral recurrence (even with contralateral blebs).

32. Management of Spontaneous Pneumothorax in Children
Seguier-Lipszyc et al, Clinical Pediatrics 50(9) 797– 802, 2011

33. Retrospective cohort study
Included: all patients 18 yo or younger with spontaneous pneumothorax
Excluded: patients with lung disease (except for mild intermittent asthma), malignancy, infection, connective tissue disease, congenital lung disease

34. 46 children were included in the study
Patients were offered VATS after 5-7 days of continued air leak or if CT demonstrated blebs/bullae.
Patients who did not undergo VATS were offered a CT after the first admission

37. VATS for the above was performed either during the initial admission or on recurrence with CT showing blebs.
The only significant difference between the two groups was the mean length of stay

40. No difference in recurrence based on CT findings
However, the study might be too small to detect differences
About a third of the patients did not get a CT scan, making the above conclusion even less clear

43. No ipsilateral recurrence in patients who underwent VATS!

44. Primary vs Delayed surgery for Spontaneous Pneumothorax in Children: Which is Better? Qureshi et al, J Pediatric Surgery, 2005.
Retrospective review
43 children with spontaneous pneumothorax

48. Recurrence rate would have to be 72% for the primary surgical treatment to be cost effective (for that particular hospital).
Caveat: only one center/one financial system; not current.

49. Should a CT scan be offered to everyone with a primary spontaneous pneumothorax?
Should we continue to administer O2 to asymptomatic patients with small pneumothoraces?
Should patients with bullae visible on CXR be offered surgical treatment right away?