Primary spontaneous pneumothorax


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also

    Background

    • Primary spontaneous pneumothorax (PSP) is a pneumothorax occurring in patients without underlying lung disease and in the absence of provoking factors such as trauma, surgery or mechanical ventilation
    • Secondary pneumothoraces may be harder to manage and have greater consequences. Advice from a respiratory physician or surgeon should be sought  

    Assessment

    Most episodes occur at rest. Consider PSP in patients with the following;  

    Symptoms

    • Acute onset chest pain – severe and/or stabbing pain, radiating to ipsilateral shoulder and increasing with inspiration (pleuritic)
    • Sudden shortness of breath
    • Anxiety, cough and vague presenting symptoms (e.g. general malaise, fatigue) are less commonly observed  

    Signs

    • General appearances may be normal
    • Sweating, tachypnoea, tachycardia (most common finding)
    • Splinting of the chest wall to relieve pleuritic pain
    • Decreased or absent breath sounds
    • Hyperresonance on percussion
    • Asymmetric lung expansion, mediastinal and tracheal shift with large pneumothorax

    Signs of tension pneumothorax

    • Deviation of the trachea to the contralateral side, tachycardia, hypotension, cyanosis
    • This is a medical emergency requiring urgent needle thoracocentesis (see thoracocentesis guideline)

    Imaging studies

    • Chest radiograph – confirms pneumothorax
      Standard erect film in inspiration. Expiratory films are not required
      • A linear shadow of visceral pleura with lack of lung markings peripheral to it indicates collapsed lung
      • Flattening or inversion of the diaphragm on the affected side
      • Mediastinal shift toward the contralateral side
      • Small pleural effusions are commonly present
      • If chest radiograph is taken in supine position, signs of pneumothorax include:
        • Deep sulcus sign; lucency along the costophrenic angle is abnormally deepened
        • Hyperlucency of the affected side

    • CT scan is not recommended routinely

    • Measuring size of the pneumothorax
      • Measurement of pneumothorax size is controversial and not age-specific
      • The size of the pneumothorax is less important than the degree of clinical compromise
      • For children >12yrs only, a pneumothorax is considered ‘large’ based on the following measurements (see diagram below)
        • Measurement of the vertical distance between the lung and thoracic cage at the apex. If  >3cm, pneumothorax is large4

          OR

        • Measurement of the distance between the lateral lung edge and chest wall at the level of the hilum; >2cm = (at least 50%)

    pneumothorax_xray pneumothorax_xray2

    Management

    See Algorithm

    pneumothorax_flowchart


    * Significant symptoms

    • Significant breathlessness
    • Hypoxia
    • Pain  

    ** For the following groups of patients, consult for further advice.

    • Age <12yrs: may have less reliable reporting of symptoms and size calculations may not be applicable
    • Secondary pneumothorax
      • Underlying lung disease e.g. Cystic Fibrosis, chronic neonatal lung disease, asthma
      • Trauma or thoracic surgery
      • Positive pressure ventilation
      • Foreign body inhalation
      • Evidence of tension pneumothorax – see thoracocentesis guideline 

    Consider consultation with local paediatric team when:

    • Large pneumothorax
    • Significant symptoms  

    When to consider transfer to tertiary centre

    • Need for ongoing drainage or underwater seal drainage
    • Deterioration during observation

      For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.  

    Consider discharge when:

    • Minimal symptoms and no deterioration during period of observation
    • Appropriate follow up arranged
    • Appropriate education regarding recurrence rate after PSP (50-61%) and recognition of symptoms