Pneumothorax in Pediatric Emergency

Definition

A pneumothorax is defined as the presence of air in the intrapleural space. Spontaneous pneumothorax is unusual. It is often associated with trauma but can be spontaneous, particularly if a person has a marfanoid habitus. It can occur secondary to a bullous or a cyst. Children with cystic fibrosis are more at risk of developing pneumothoraces. Consider pneumothorax in a child presenting with pleuritic chest pain or shortness of breath. There may be a previous history of pneumothorax. On examination, there may be reduced air entry and a deviated trachea (away from the collection) and hyper-resonance, but no added breath sounds.

Management

In small pneumothoraces, a conservative approach is appropriate. Where there is less than 30% reduction of total lung capacity (TLC), initial high flow oxygen will help absorb the intrapleural air and in most cases the pneumothorax will resolve over a 1–2 week time scale. Where there is between 30–50% reduction in TLC there are three steps depending on response:
• Oxygen therapy in cases where there are no major symptoms and observation and repeat X-ray over 12 hours.
• Oxygen therapy and a needle thoracocentesis using a small catheter attached to a 3-way tap. This is inserted in the second intercostal space above the rib and in the midclavicular line. Air is aspirated, the tap is closed off and chest X-ray repeated over the following 6 hours. If the air has not reaccumulated, the catheter can be removed and the patient reviewed 24 hours later with repeat X-ray.
• Insertion of an intercostal drain with a valve or underwater seal. This should be placed in the anterior axillary line in the fourth intercostal space.

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