What is the initial approach to treating pectus excavatum?

Initial Approach to Treating Pectus Excavatum

The initial approach to treating pectus excavatum should be conservative management with targeted exercises and rehabilitation for mild to moderate cases, progressing to vacuum bell therapy for patients aged 10-15 years, and considering surgical correction (Nuss procedure) only for patients 16 years and older with significant symptoms or deformity. 1

Assessment and Classification

Before determining treatment, a thorough evaluation should include:

• Assessment of symptom severity (cardiopulmonary compromise, psychological impact)
• Echocardiogram to evaluate cardiac function, especially in patients with Marfan syndrome 2
• Chest imaging to determine the severity of the deformity
• Pulmonary function tests if respiratory symptoms are present

Treatment Algorithm Based on Age and Severity

Children Under 10 Years

• First-line treatment: Targeted physical therapy and rehabilitation exercises 1
• Monitor for progression of deformity
• No surgical intervention recommended at this age

Children 10-15 Years

• First-line treatment: Continue targeted exercises and rehabilitation
• Add-on therapy: Vacuum bell therapy for compliant patients 1, 3
  • Device selection based on patient's size
  • Initial application: 30 minutes twice daily
  • May increase to several hours daily as tolerated
  • Immediate sternum lifting has been documented via CT scans 4

Patients 16 Years and Older

• Non-surgical options: Continue vacuum bell therapy if showing improvement
• Surgical consideration: Nuss procedure (minimally invasive repair of pectus excavatum) for:
  • Patients with cardiopulmonary compromise
  • Significant psychological distress affecting quality of life
  • Failure of conservative management 1

Indications for Surgical Intervention

Surgery should be considered when:

1. Cardiopulmonary compromise is present (hemodynamic effects or respiratory limitations)
2. Significant psychological impact affecting quality of life 2
3. Conservative management has failed after adequate trial
4. Patient is of appropriate age (typically ≥16 years) 1

Special Considerations

Patients with Marfan Syndrome

• Echocardiogram evaluation is mandatory before considering any repair
• Delay surgical repair if aortic root dilation is present and approaching surgical thresholds (≥4.5 cm)
• Cardiovascular protection with beta-blockers or angiotensin receptor blockers should be initiated 2

Vacuum Bell Therapy Details

• Three different sizes available based on patient age
• Creates vacuum at anterior chest wall
• Immediate sternum lifting observed
• Preliminary results show success in selected patients
• Long-term results (>15 years) are still lacking 3, 4

Monitoring and Follow-up

• Regular follow-up to assess improvement with conservative management
• For patients with Marfan syndrome: echocardiogram every 2-3 years if aortic root diameter is normal
• Annual evaluation for scoliosis until adult height is reached 2

Pitfalls and Caveats

1. Avoid rushing to surgical intervention in young children before trying conservative approaches
2. Recognize that vacuum bell therapy requires consistent application and patient compliance
3. In patients with Marfan syndrome, cardiac issues take precedence over cosmetic repair
4. Surgical repair should be performed by experienced surgeons familiar with the Nuss procedure
5. The Nuss procedure requires the implanted bar to remain in place for approximately 3 years 1

By following this structured approach based on age, severity, and associated conditions, most patients with pectus excavatum can achieve significant improvement with appropriate treatment.