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Pneumothorax, Pediatric

Basics

Description

- Barotrauma - Mechanical ventilation - Cough (if severe enough) - Vaginal birth

- Iatrogenic - Central venous catheter placement - Bronchoscopy (especially with biopsy)

- Airway occlusion - Mucus plugging (asthma) - Foreign body - Meconium aspiration

- EKG - Diminished amplitude of the QRS voltage - Rightward shift of the QRS axis (if left-sided pneumothorax)

- Arterial blood gas - Po2 can frequently be decreased. - Pco2 - Elevated with respiratory compromise - Decreased from hyperventilation

- Chest radiograph - Radiolucency of the affected lung - Lack of lung markings in the periphery of the affected lung - Collapsed lung on the affected side - Possible pneumomediastinum with subcutaneous emphysema

- Pitfalls: - Not considering the diagnosis in otherwise healthy patients - Confusing the symptoms with those of an underlying lung disease - Inserting a needle into a cyst or bleb (can cause a tension pneumothorax with rapid respiratory compromise)

- Pulmonary - Congenital lung malformations - Cysts (i.e., bronchogenic cysts) - Cystic adenomatoid malformation - Congenital lobar emphysema

- Acquired emphysema - Hyperinflation of the lung - Postinfectious pneumatocele - Bullae formation

- Oxygen - Used to keep Sao2 ≥95% - Breathing 100% oxygen - Can speed the intrapleural air 's reabsorption into the bloodstream, hastening lung reexpansion - Useful for treating smaller pneumothoraces, especially in neonates

- Needle thoracentesis: useful for evacuation of the pleural air in simple, uncomplicated spontaneous pneumothorax - Chest tube drainage - Used for evacuation of the pleural air in recurrent, persistent, or complicated pneumothoraces and cases with significant underlying lung disease - Chest tube should be left in (usually 2 " 4 days) until - Most air is reabsorbed - No reaccumulation of air is seen on sealing of the chest tube

- Pleurodesis - Used to attach the lung to the intrathoracic chest wall to prevent reoccurrence of a pneumothorax - Useful in cases of recurrent pneumothorax or if the pneumothorax is unresponsive to chest tube drainage (i.e., CF, malignancy) - Mechanism of action: The surface of the lung becomes inflamed and adheres to the chest wall via the formation of scar tissue. - 2 commonly used methods: - Surgical pleurodesis: - Mechanical abrasion of part of the lung or pleurectomy - Advantages: very effective; low reoccurrence rate; site specific (limits affected area) - Disadvantages: requires surgery and general anesthesia; contraindicated if patient is unstable

Abnormal collection of free air or gas in the pleural space

Epidemiology

Depends on the underlying lung disease

Incidence

  • Spontaneous pneumothoraxMale > female (1.4 to 10.1:1)Peak incidence: 10 " 30 years
  • Pneumothorax with cystic fibrosis (CF)For overall CF population: 3.5 " 8%CF patients >18 years: 16 " 20%Risk factors for pneumothorax:More severe diseaseDecreased pulmonary function (i.e., forced expiratory volume in 1 second [FEV1] <30 " 50%)Colonization with Pseudomonas aeruginosa, Burkholderia cepacia, or Aspergillus

Risk Factors

  • Asthma
  • CF
  • Pneumonia
  • Collagen vascular diseases

Pathophysiology

  • Air can enter the pleural space via the following:Chest wall (i.e., penetrating trauma)Intrapulmonary (i.e., ruptured alveoli)
  • Usually, collapse of the lung on the affected side seals the leak.
  • If a ball valve mechanism ensues, however, air can accumulate in the thoracic cavity, causing the development of a tension pneumothorax (a medical emergency).

Etiology

  • Spontaneous (secondary to rupture of apical blebs)
  • Mechanical traumaPenetrating injury (i.e., knife or bullet wound)Blunt trauma (i.e., auto accident)
  • BarotraumaMechanical ventilationCough (if severe enough)Vaginal birth
  • IatrogenicCentral venous catheter placementBronchoscopy (especially with biopsy)
  • Infection: most common organismsStaphylococcus aureusStreptococcus pneumoniaeMycobacterium tuberculosisBordetella pertussisPneumocystis jiroveci
  • Airway occlusionMucus plugging (asthma)Foreign bodyMeconium aspiration
  • Bleb formation (i.e., idiopathic, secondary to CF)
  • Malignancy
  • Catamenial

Diagnosis

History

  • May be asymptomatic (pneumothorax discovered on chest film obtained for other reasons)
  • Cough
  • Shortness of breath
  • Dyspnea
  • Pleuritic chest pain that is usually sudden in onset and localized to apices (referred pain to shoulders)
  • Respiratory distress
  • Underlying medical problems which increases risk for pneumothorax
  • Activity prior to developing symptoms that might have caused the pneumothorax:Heavy liftingIncreased coughing

Physical Exam

  • May be normal
  • Decreased breath sounds on the affected side
  • Decreased vocal fremitus
  • Hyperresonance to percussion on the affected side
  • Tachypnea
  • Tachycardia
  • Shortness of breath
  • Respiratory distress
  • Shifting of the cardiac point of maximal impulse away from the affected side
  • Shifting of the trachea away from the affected side
  • Subcutaneous emphysema
  • Cyanosis
  • Scratch sign (heard through the stethoscope): A loud scratching sound is heard when a finger is gently stroked over the area of the pneumothorax.

Diagnostic Tests & Interpretation

  • EKGDiminished amplitude of the QRS voltageRightward shift of the QRS axis (if left-sided pneumothorax)

Lab

  • Arterial blood gasPo2 can frequently be decreased.Pco2Elevated with respiratory compromiseDecreased from hyperventilation
  • Pulse oximetryUseful for assessing oxygenation

Imaging

  • Chest radiographRadiolucency of the affected lungLack of lung markings in the periphery of the affected lungCollapsed lung on the affected sidePossible pneumomediastinum with subcutaneous emphysema
  • Chest CTUseful for finding small pneumothoracesCan help distinguish a pneumothorax from a bleb or cystHelpful for locating small apical blebs associated with spontaneous pneumothoraces

Diagnostic Procedures/Other

  • Pitfalls:Not considering the diagnosis in otherwise healthy patientsConfusing the symptoms with those of an underlying lung diseaseInserting a needle into a cyst or bleb (can cause a tension pneumothorax with rapid respiratory compromise)

Differential Diagnosis

  • PulmonaryCongenital lung malformationsCysts (i.e., bronchogenic cysts)Cystic adenomatoid malformationCongenital lobar emphysemaAcquired emphysemaHyperinflation of the lungPostinfectious pneumatoceleBullae formation
  • MiscellaneousDiaphragmatic herniaInfections (i.e., pulmonary abscess)Muscle strainPleurisy (i.e., pleuritis)Rib fracture

Treatment

General Measures

  • Stabilization of the patient
  • Evacuation of the pleural airShould be done urgently if a tension pneumothorax is suspectedIn small asymptomatic pneumothoraces, observation of the patient is indicated.
  • Treat the underlying condition predisposing for the pneumothorax:Antibiotics for any underlying infectionBronchodilators and anti-inflammatory agents for asthma attacks
  • OxygenUsed to keep Sao2 ≥95%Breathing 100% oxygenCan speed the intrapleural air 's reabsorption into the bloodstream, hastening lung reexpansionUseful for treating smaller pneumothoraces, especially in neonates

Surgery/Other Procedures

  • Needle thoracentesis: useful for evacuation of the pleural air in simple, uncomplicated spontaneous pneumothorax
  • Chest tube drainageUsed for evacuation of the pleural air in recurrent, persistent, or complicated pneumothoraces and cases with significant underlying lung diseaseChest tube should be left in (usually 2 " 4 days) untilMost air is reabsorbedNo reaccumulation of air is seen on sealing of the chest tube
  • Surgical removal of pulmonary blebsBlebs have a high rate of rupturing with resultant pneumothorax.In patients with established pneumothoraces, the blebs should be removed or oversewn to prevent reoccurrence of the pneumothorax (blebs have a high rate of reoccurrence if not repaired).Thoracotomy versus video-assisted thoracoscopic surgery (VATS)
  • PleurodesisUsed to attach the lung to the intrathoracic chest wall to prevent reoccurrence of a pneumothoraxUseful in cases of recurrent pneumothorax or if the pneumothorax is unresponsive to chest tube drainage (i.e., CF, malignancy)Mechanism of action: The surface of the lung becomes inflamed and adheres to the chest wall via the formation of scar tissue.2 commonly used methods:Surgical pleurodesis:Mechanical abrasion of part of the lung or pleurectomyAdvantages: very effective; low reoccurrence rate; site specific (limits affected area)Disadvantages: requires surgery and general anesthesia; contraindicated if patient is unstableChemical pleurodesisChemicals are used to cause inflammation.Chemicals commonly used: talc, tetracycline, minocycline, doxycycline, quinacrineAdvantages: requires no surgery or general anesthesiaDisadvantages: less effective than surgery; generalized inflammation (rather than site-specific; makes future thoracic surgery more difficult; painful)

Ongoing Care

Follow-up Recommendations

Symptomatic relief within seconds of the air being evacuated

Patient Monitoring

Sign to watch for: inability to remove the chest tube without reaccumulation of air (suggestive of a bronchopulmonary fistula; requires surgical exploration if no improvement in 7 " 10 days)

Prognosis

  • Depends on the underlying cause of the pneumothorax
  • If simple, spontaneous pneumothorax, recovery is excellent
  • CF: Development of pneumothorax associated with increased morbidity and mortality (median survival after 1st pneumothorax is 4 years).

Complications

  • Pain
  • Hypoxia
  • Respiratory distress
  • Tension pneumothoraxHypoxiaHypercarbia with acidosisRespiratory failure
  • Pneumomediastinum with subcutaneous emphysema
  • Bronchopulmonary fistula

Additional Reading

  • Baumann MH. Management of spontaneous pneumothorax. Clin Chest Med. 2006;27(2):369 " 381. [View Abstract]
  • Briassoulis GC, Venkataraman ST, Vasilopoulos AG, et al. Air leaks from the respiratory tract in mechanically ventilated children with severe respiratory disease. Pediatr Pulmonol. 2000;29(2):127 " 134. [View Abstract]
  • Dotson K, Johnson LH. Pediatric spontaneous pneumothorax. Pediatr Emerg Care. 2012;28(7):715 " 723. [View Abstract]
  • Dotson K, Timm N, Gittleman M. Is spontaneous pneumothorax really a pediatric problem? A national perspective. Pediatr Emerg Care. 2012;28(4):340 " 344. [View Abstract]
  • Flume PA, Strange C, Ye X, et al. Pneumothorax in cystic fibrosis. Chest. 2005;128(2):720 " 728. [View Abstract]
  • Johnson NN, Toledo A, Endom EE. Pneumothorax, pneumomediastinum, and pulmonary embolism. Pediatr Clin North Am. 2010;57(6):1357 " 1383. [View Abstract]
  • Noppen M. Management of primary spontaneous pneumothorax. Curr Opin Pulm Med. 2002;9(4):272 " 275. [View Abstract]
  • Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000;342(12):868 " 874. [View Abstract]
  • Ullman EA, Donley LP, Brady WJ. Pulmonary trauma emergency department evaluation and management. Emerg Med Clin North Am. 2003;21(2):291 " 313. [View Abstract]

Codes

ICD09

  • 512.89 Other pneumothorax
  • 512.81 Primary spontaneous pneumothorax
  • 860.0 Traumatic pneumothorax without mention of open wound into thorax
  • 512.0 Spontaneous tension pneumothorax
  • 512.1 Iatrogenic pneumothorax

ICD10

  • J93.9 Pneumothorax, unspecified
  • J93.11 Primary spontaneous pneumothorax
  • S27.0XXA Traumatic pneumothorax, initial encounter
  • J93.0 Spontaneous tension pneumothorax
  • J93.83 Other pneumothorax
  • J95.811 Postprocedural pneumothorax

SNOMED

  • 36118008 Pneumothorax (disorder)
  • 80423007 Spontaneous pneumothorax (disorder)
  • 90070003 Traumatic pneumothorax (disorder)
  • 233645004 Tension pneumothorax (disorder)
  • 441536000 Iatrogenic pneumothorax (disorder)

FAQ

  • Q: Can a pneumothorax reoccur?
  • A: Reoccurrence depends on the underlying cause of the pneumothorax. Spontaneous pneumothorax reoccurrence rates:Observation alone: 20 " 50%If thoracentesis performed: 25 " 50%If chest tube drainage performed: 32 " 38%Overall reoccurrence rate: 16 " 52%
  • Chemical pleurodesis reoccurrence rates:Tetracycline: 25%Talc: 8 " 10%
  • Surgical pleurodesis reoccurrence rates:VATS: 13%Thoracotomy: 3%Thoracotomy with pleurectomy: 0 " 4%
  • CF reoccurrence rates:If no drainage attempted: 68%Thoracentesis alone: 90%Chest tube drainage alone: 72%Chemical pleurodesis:Tetracycline: 42 " 86%Quinacrine: 12.5%Talc: 8%Surgical pleurodesis: thoracotomy with pleurectomy: 0 " 4%