What is the treatment for an 11-year-old male child with spontaneous pneumothorax?

Treatment of Spontaneous Pneumothorax in an 11-Year-Old Male Child

Simple aspiration should be attempted as first-line treatment for this 11-year-old male with spontaneous pneumothorax, followed by chest tube drainage if aspiration fails. 1

Initial Assessment and Management

• Determine if this is a primary or secondary pneumothorax (primary being without underlying lung disease, secondary occurring with pre-existing lung conditions) 1
• Assess clinical stability: respiratory rate, heart rate, blood pressure, oxygen saturation, and ability to speak in full sentences 1
• Evaluate size of pneumothorax on chest radiograph (small: <3 cm apex-to-cupola distance; large: ≥3 cm) 1
• Administer high-flow oxygen (10 L/min) if hospitalized for observation, which can increase the rate of pneumothorax reabsorption up to four-fold 1

Treatment Algorithm Based on Clinical Presentation

For Small Primary Pneumothorax with Minimal Symptoms:

• Observation alone may be sufficient for small, closed pneumothoraces with minimal symptoms 1
• Patient does not require hospital admission but should be instructed to return if breathlessness develops 1
• Follow-up chest radiograph after 2 weeks to confirm resolution 1

For Symptomatic Primary Pneumothorax:

1. Simple aspiration as first-line treatment 1

   • Success rates of 59-83% in primary pneumothorax 1
   • Consider catheter aspiration of pneumothorax (CASP) where equipment and experience are available 1
   • Repeated aspiration is reasonable if first attempt fails and <2.5L was aspirated initially 1

2. If aspiration fails, proceed to intercostal tube drainage 1

   • Use small-bore catheter (≤14F) or moderate-sized chest tube (16F-22F) 1
   • Connect to either a Heimlich valve or water seal device 1
   • Apply suction if the lung fails to re-expand quickly 1

For Large or Secondary Pneumothorax:

• Intercostal tube drainage is recommended as initial treatment 1
• Use a 16F-22F chest tube for most patients 1
• Consider a larger tube (24F-28F) if large air leak is anticipated 1

Pediatric-Specific Considerations

• In pediatric patients, tube thoracostomy is required in approximately 74% of spontaneous pneumothorax cases 2
• Mean duration of chest tube drainage in pediatric primary spontaneous pneumothorax is approximately 7.2 days 2
• Consider CT scan to identify apical bullae or blebs, which are found in the majority of pediatric PSP patients 3, 4
• If air leak persists beyond 5 days, surgical intervention may be necessary 5

Surgical Management

• Consider surgical intervention if:
  • Persistent air leak beyond 5 days 5
  • Recurrent pneumothorax 3, 6
  • Bilateral pneumothoraces 3
• Video-assisted thoracoscopic surgery (VATS) has become the preferred approach over open thoracotomy (89.3% vs 10.7%) 6
• Surgical procedures typically include:
  • Bleb/bulla excision 4, 6
  • Mechanical pleurodesis 4, 6

Chest Tube Removal and Follow-up

• Remove chest tube in a staged manner to ensure air leak has resolved 1
• Confirm resolution with chest radiograph after discontinuing any suction 1
• Advise patient to avoid air travel until follow-up chest radiograph confirms complete resolution 1
• Diving should be permanently avoided unless bilateral surgical pleurectomy has been performed 1

Common Pitfalls to Avoid

• Failing to intervene in breathless patients regardless of pneumothorax size on chest radiograph 1
• Underestimating the risk of tension pneumothorax, especially with marked breathlessness even in small pneumothoraces 1
• Using fully occlusive dressings without a mechanism for air to escape if treating an open pneumothorax 7
• Delaying surgical referral when air leak persists beyond 5 days 5