Pediatric Pneumothorax Treatment & Management

Updated: Oct 16, 2019
  • Author: Andres Carrion, MD, FAAP; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
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Treatment

Approach Considerations

Treatment for spontaneous pneumothorax in children varies based on the size of the pneumothorax, severity of respiratory distress, and presence of underlying lung disease. Many cases of spontaneous pneumothorax resolve with conservative therapies. Individuals with small pneumothoraces who are asymptomatic can be observed and do not necessarily require intervention. Pneumothorax should resolve within 12 days. Although subcutaneous emphysema can be extensive, it does not create an increased risk of local infections. Management of subcutaneous emphysema should be focused on symptoms. [3, 6]

Administering 100% oxygen via a nonrebreathing face mask hastens the absorption of loculated gas. High concentrations of supplemental oxygen create a partial-pressure gradient between the pleural cavity and end-capillary blood by decreasing the partial-pressure contribution of nitrogen (nitrogen washout), increasing reabsorption of gas from the pleural cavity. [2] This treatment should not be continued for long periods. The patient should be observed and chest radiography should be repeated to look for improvement. For secondary spontaneous pneumothorax, underlying disease should be treated.

Large (occupying >30% of the hemithorax) or complicated pneumothorax requires hospitalization and direct mechanical evacuation of pleural air. Clinically stable patients with a primary spontaneous pneumothorax can be treated with needle aspiration. Clinically unstable patients and most patients with underlying lung disease (secondary spontaneous pneumothorax) should be treated with chest tube insertion. A patient with a traumatic pneumothorax is best treated with a chest tube, because the condition may rapidly convert into a tension pneumothorax, especially if positive-pressure ventilation is applied. A tension pneumothorax requires immediate decompression with needle thoracostomy, followed by tube thoracostomy. [1]

In certain conditions with recurrent pneumothorax (such as cystic fibrosis), identification of an apical bleb sometimes requires thoracoscopic resection, and if no bleb is found, then either thoracoscopic or sclerosing pleurodesis is indicated.

See the image below.

Pneumothorax chest tube. Pneumothorax chest tube.
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Medical Care

There is no general consensus on the best setting to monitor pediatric patients with small pneumothoraces; however, a cautious approach in these patients is usually appropriate. Clinically stable patients with small, primary spontaneous pneumothoraces can be initially observed in the hospital with administration of 100% supplemental oxygen via a nonrebreathing facemask. If the pneumothorax is small and is resolving within 12 hours, patients can generally be observed in an outpatient setting. Younger children may require longer observation in a hospital setting.

Other supportive care, including pain medications, should be provided as needed to all patients with pneumothorax.

Patients should have close outpatient follow-up and should also be given specific instructions to seek further medical care should they develop any new or worsening dyspnea or other respiratory symptoms.

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Surgical Care

Evacuation of the pleural space is recommended for a large pneumothorax or in patients with significant pain, dyspnea, or hypoxemia. Pneumothorax in adults is generally considered to be large if there is 3 or more centimeters of air between the pleural line and the apical chest wall; however, it is difficult to determine the size of a pneumothorax in a pediatric patient as the thoracic size differs based on age and the size of the patient.

Only pleurodesis (intrapleural instillation of a sclerosing agent such as talc, fibrin glue, and antibiotics), video-assisted thoracoscopic surgery (VATS), and thoracotomy reduce the risk of future recurrence. Pleurodesis may be indicated for the first episode of a secondary pneumothorax owing to the high incidence of recurrence or after a recurrence of a primary pneumothorax.

Needle decompression is appropriate for clinically stable patients with large primary spontaneous pneumothoraces. In needle aspiration, air is manually withdrawn using an intravenous catheter connected to a syringe and three-way stopcock. Follow-up chest radiography should be performed approximately 4 hours after the procedure, and catheter can be removed at that time if adequate lung expansion has occurred. A persistent air leak is likely present if a substantial volume of air can be continuously withdrawn during needle aspiration. Air can also reaccumulate as a result of a persistent air leak after needle decompression; therefore, serial chest radiographs are important during close follow-up. Patients with reaccumulation of air require thoracostomy tube placement.

Thoracostomy (chest) tube is required in patients in whom needle aspiration fails as a result of a persistent air leak, patients with recurrent spontaneous pneumothorax, and some patients with secondary spontaneous pneumothorax. Pleurodesis can be performed at the time of thoracostomy tube placement to help decrease risk of recurrence of pneumothorax.

VATS with pleurodesis is generally indicated in patients with primary spontaneous pneumothorax and persistent air leak that fails to improve with thoracostomy tube. VATS is also considered in recurrent primary or secondary spontaneous pneumothorax, but it should be considered on a case-by-case basis. [7, 10, 11]

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Complications

Complications directly related chest tube insertion may result in significant bleeding, infection, or both. Other complications of thoracostomy include pain and injury to thoracic neurovascular structures. Insertion too far below the recommended fourth or fifth intercostal space may result in intra-abdominal placement, with possible abdominal visceral or diaphragmatic injury.

Tension pneumothorax is a rare but serious potential complication of either primary or secondary spontaneous pneumothorax.

Also see Presentation/Complications.

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Consultations

The following consultations may be needed:

  • Critical care specialist
  • Surgeon
  • Pulmonologist
  • Interventional radiologist
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Activity

To decrease the risk of recurrence, children should avoid scuba diving. Additionally, on a temporary basis, 4 weeks after resolution of pneumothorax, all air travel, contact sports, and playing bass or woodwind musical instruments is to be avoided. [3]

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Prevention

It is strongly encouraged to avoid smoking exposure, and efforts should be directed at smoking cessation after the development of a pneumothorax.

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Long-Term Monitoring

There is a high rate of pneumothorax recurrence after a VATS procedure or chest tube drainage. Close follow-up is recommended.

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