Evidence-based management of paediatric primary spontaneous pneumothorax

LARGE primary spontaneous pneumothorax (2023 French Guidelines definition): Do radiographic size matter in pediatric patients? A comparative analysis

PURPOSE

Our aim was to explore the applicability of the definition of "large" primary spontaneous pneumothorax (PSP) of adult guidelines to pediatric patients.

METHODS

We performed a retrospective monocentric analysis of first-episodes of PSP (Period: January 2010-January 2023). We defined large PSP according to French SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines.

INCLUSION CRITERIA

age 1-18 years-old, follow-up ≥ 1 year. We performed a comparative analysis between large and nonlarge PSP. We reported the categorical variables as frequencies, and continuous as median and range. We compared categorical variables using Chi-Square or Fisher test, and continuous using U Mann-Whitney test. p < 0.05 was considered significant.

RESULTS

The population consisted of 49 patients, 15 (30%) with large PSP. We found no significant differences at presentation between large and nonlarge PSP regarding age, sex, side, BMI, oxygen saturation, respiratory rate and hearth rate. Conservative first-line management was used significantly less for large PSP (26% vs. 82%, p = 0.0003), while drain more (46% vs. 8%, p = 0.005). The groups were similar regarding surgery. Large PSP had a significantly longer hospitalization (7 days vs. 4 days, p = 0.003). The incidence of first-line management failure was similar between the groups. During the follow-up, we found no significant differences regarding ipsilateral recurrence (33% vs. 17%, p = 0.275), and contralateral occurrence (0% vs. 5%, p = 1.000), need for drain (6% vs. 5%, p = 1.000), or surgery (33% vs. 14%, p = 0.246).

CONCLUSIONS

In the first-line, large PSP were treated significantly less conservatively and more drained. Radiographic size of the pneumothorax does not seem to have an impact on first-line treatment failure and follow-up outcomes.

Conservative and operative management of spontaneous pneumothorax in children and adolescents: Are we abusing of CT?

BACKGROUND

No age-specific pediatric guidelines exist for the management of spontaneous pneumothorax (SP) in children and adolescents. Treatment remains heterogeneous and center dependent. The role of computed tomography (CT) has yet to be defined.

AIMS

Review the management of SP in children and adolescents, with emphasis on conservative management and role of CT.

METHODS

Retrospective analysis of 61 consecutive patients with SP at single tertiary center. Clinical, radiological, surgical data, follow-up, and outcomes were revised.

RESULTS

First-line management was conservative for 32 (53%) patients and operative for 29 (47%). Asymptomatic/paucisymptomatic patients managed conservatively experienced less first-line treatment failure. Furthermore, the patients needing at least a chest drain or surgery during the follow-up were significantly lower in the conservative group. Conservative and operative patients showed no significant differences regarding ipsilateral recurrences or contralateral occurrences. Of the 61 overall CTs performed, 14 (23%) had an impact on management. Forty-three (70%) patients had at least a CT, in 22 (51%) the CT was positive for blebs. For 10 of these patients (45%) the presence of blebs had an impact on management. Patients with and without blebs showed no differences regarding ipsilateral recurrence, contralateral occurrences, or the need for at least a chest drain or surgery during the follow-up.

CONCLUSIONS

First-line conservative management had a significantly shorter hospitalization and better outcome, with a similar incidence of recurrences. The presence of blebs at CT does not predict the risk of recurrence. The CT scan should be reserved for a small number of selected patients who have post-VATS refractory or recurrent pneumothorax.

Evaluation and Management of Primary Spontaneous Pneumothorax in Adolescents and Young Adults: A Systematic Review From the APSA Outcomes & Evidence-Based Practice Committee

INTRODUCTION

Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee performed a systematic review of the literature to develop evidence-based recommendations.

METHODS

Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL, Elsevier Scopus, and Wiley Cochrane Central Register of Controlled Trials databases were queried for literature related to spontaneous pneumothorax between January 1, 1990, and December 31, 2020, addressing (1) initial management, (2) advanced imaging, (3) timing of surgery, (4) operative technique, (5) management of contralateral side, and (6) management of recurrence. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed.

RESULTS

Seventy-nine manuscripts were included. Initial management of adolescent and young adult primary spontaneous pneumothorax should be guided by symptoms and can include observation, aspiration, or tube thoracostomy. There is no evidence of benefit for cross-sectional imaging. Patients with ongoing air leak may benefit from early operative intervention within 24-48 h. A video-assisted thoracoscopic surgery (VATS) approach with stapled blebectomy and pleural procedure should be considered. There is no evidence to support prophylactic management of the contralateral side. Recurrence after VATS can be treated with repeat VATS with intensification of pleural treatment.

CONCLUSIONS

The management of adolescent and young adult primary spontaneous pneumothorax is varied. Best practices exist to optimize some aspects of care. Further prospective studies are needed to better determine optimal timing of operative intervention, the most effective operation, and management of recurrence after observation, tube thoracostomy, or operative intervention.

LEVEL OF EVIDENCE

Level 4.

TYPE OF STUDY

Systematic Review of Level 1-4 studies.

Spontaneous pneumothorax or no pneumothorax at all?

Care of a simple pneumothorax in a paediatric patient is often anything but simple, and a refractory and complex pneumothorax requires thoughtful and deliberate care https://bit.ly/3NFAk9S.

Trends in recurrence of primary spontaneous pneumothorax in young population after treatment for first episode based on a nationwide population data

The aim of this study is to identifying post treatment recurrence rates in pneumothorax patients under 35 and without any comorbidities according to the treatment types, gender, and age categories based on nationwide population data. Clinical information of pneumothorax patients was extracted from the Korean National Health Insurance Service (NHIS) database between January 2002 and December 2020. Enrolled patients were categorized into two groups; (1) Group I, those who underwent conservative management including pain relief, oxygen therapy, and closed thoracostomy, and (2) Group II, surgical intervention. Recurrence rates were compared according to age, gender, and type of treatment. Surgical intervention was performed in 25.6% patients as first treatment. The overall recurrence rate was 20.3%. Male patients showed a higher 5-year recurrence rate than female (20.8% vs. 10.9%, p < 0.001). Those with conservative management showed lower 5-year recurrence rates than those with surgical treatment (7.9% vs. 23.7%, p < 0.001). The 5-year recurrence rates of patients aged 14≤, and < 20 was higher than other age groups (29.2% vs. 4.5 and 11.9%, p < 0.001). Surgical intervention, male gender and aged under 20 showed association with higher recurrence rates.

Management of primary spontaneous pneumothorax in children: Current practices among Turkish pediatric surgeons

Background

This study aims to evaluate current practices in the management of primary spontaneous pneumothorax among Turkish pediatric surgeons.

Methods

Between October 2021 and November 2021, an online survey comprising 19 questions was delivered to all members of the Turkish Association of Pediatric Surgeons (TAPS). A total of 74 respondents (42 males, 32 females; mean age: 42.3±7.9 years; range, 29 to 61 years) were included.

Results

The response rate was 17.1% among all society members. The rate of utilization of computed tomography in the initial admission was 27.4%, and the rate of use in cases requiring surgical treatment was 78.4%. A total of 81% of surgeons reported that the size of the pneumothorax influenced management. For the first episode of primary spontaneous pneumothorax, 75.7% of surgeons opted for chest tube drainage, 14.9% for only oxygen administration, 4.1% for needle aspiration, and none of the surgeons preferred video-assisted thoracoscopic surgery. For patients with a persistent air leak after chest tube placement, there was a wide variation in the duration of observation before performing surgery. Video-assisted thoracoscopic surgery was the most preferred surgical intervention (75.3%) and the most preferred surgical method was stapled bullectomy (43.8%).

Conclusion

There are practice variations in the management of pediatric primary spontaneous pneumothorax among the society members. However, the majority of members seem to agree on the use of computed tomography, initial treatment, and surgical interventions.

Pediatric primary spontaneous pneumothorax: a comparison of treatment at pediatric surgery vs. thoracic surgery departments

Management of pediatric Primary Spontaneous Pneumothorax (PSP) is controversial and based on guidelines on adults. Therapeutic strategies include: observation, needle aspiration, chest drain, or surgery. We aimed to assess: i) differences in the management of PSP in pediatric vs. adult departments; ii) risk of recurrence associated to each therapeutic choice; iii) management of "large" pneumothorax (i.e. >3cm at the apex on chest X-Ray); iv) role of CT scan in addressing the treatment. We reviewed all PSP treated at Pediatric Surgery Unit (PSU) and Thoracic Surgery Unit for adults (TSU) in a 10-year period (2011 to 2020). We included a total of 42 PSP: 30/42 1st episodes and 12/42 recurrences. Among the 30/42 1st episodes, 15/30 were managed in the PSU and 15/30 in the TSU. Observation was significantly most common among PSU patients (9/15, 60%) vs. TSU cases (1/15, 6.7%; p=0.005]. Chest drain placement was reduced in PSU (3/15, 20%) vs. TSU (12/15, 80%; p=0.002). Observational was associated with a reduced risk of recurrence (0/10, 0%) compared to chest drain (7/15, 46.7%; p=0.01). Management of 20/42 "large" pneumothorax was: 4/20 (20%) observation, 10/20 (50%) chest drain, 2/20 (10%) needle aspiration, 4/20 (20%) surgery. Twentythree/ 29 PSP (79.3%) underwent CT-scan after the first episode. Bullae were detected in 17/23 patients and 5/17 (29.4%) had seven episodes of recurrence. PSP patients treated by PSU were more likely to receive clinical observation. Those managed by TSU were mostly treated by chest drain. Observation seems an effective choice for clinically stable PSP, with low risk of recurrence at a mid-term follow-up. CT-scan seems not to detect those patients at higher risk of recurrence.

Early risk factors of operative management for hospitalization children with spontaneous pneumothorax

BACKGROUND

The optimal timing of operative management in children with primary spontaneous pneumothorax (PSP) remains controversial. This study sought to determine early risk factors for failure of chest tube nonoperative management during the initial hospitalization in adolescents with PSP.

METHODS

A retrospective review was conducted for children (aged ≤18 years) admitted to a single tertiary care referral center for their first presentation of a PSP managed with at least 48 h of chest tube decompression (CTD) alone. Patient outcomes and early risk factors for operative management were analyzed by multivariate regression.

RESULTS

Of the 39 patients who met inclusion criteria, 15 (38.5%) patients failed nonoperative treatment while 24 (61.5%) patients were managed with CTD therapy alone. Progression to thoracoscopic surgery was associated with longer CTD of 8 vs 3 days and hospital length of stay of 9 vs 4 days when compared to nonoperative management (p < 0.001, both). Air leak and increase in pneumothorax size at 24 h after CTD were independently associated with progression to surgery (p = 0.007, p = 0.002). Combined, these risk factors were associated with a significant increase in recurrence (OR 6.00, 95% CI 1.11-41.11, p = 0.048). There were no significant differences between PSP management strategies regarding cumulative radiation exposure or 2 year recurrence.

CONCLUSIONS

Air leak or increasing pneumothorax size within 24 h of CTD are highly correlated with failed nonoperative management during the initial hospitalization in pediatric patients with PSP. This data may be useful in the development of pediatric-specific treatment algorithms to optimally manage these patients.

LEVEL OF EVIDENCE

Treatment study, Level III.

Update in management of paediatric primary spontaneous pneumothorax

Paediatric spontaneous pneumothorax (PSP) management continues to lack paediatric-specific guideline recommendations. There have been increasing reports of paediatric retrospective case studies supplemented by important well designed RCT (predominantly) adult studies. Taken together, these suggest that conservative management may have an increasing role to play in the management of PSP and that aspiration may have limited utility as a first line intervention. Our local experience, as part of a multicentre retrospective analysis and subsequent audit of management since, corroborates recent published data: it highlights an increasing trend towards conservative management in spontaneous pneumothorax with similar rates of recurrence, compared to intervention, and low use of aspiration with similarly low success rates. We have therefore updated our local practice guidelines and share these with readers. Specifically, we have removed aspiration in the management of primary spontaneous pneumothorax and reserved intervention for children who are clinically unstable or show evidence of increasing air leak irrespective of pneumothorax size. Whilst the success of this change in clinical practice will need to be reviewed in the next 5-10 years, the overall low incidence of the condition, demands a multicentre, and probably multinational, collaborative approach to allow the best chance of obtaining definitive evidence to guide clinical paediatric management.

Interventional Bronchus Occlusion Using Amplatzer Devices - A Promising Treatment Option for Children with Persistent Air Leak

BACKGROUND

Persistent air leak (PAL) is a severe complication of secondary spontaneous pneumothorax (SSP). Surgical interventions are usually successful when medical treatment fails, but can be associated with significant complications and loss of potentially recoverable lung parenchyma.

METHODS

Retrospective analysis of efficacy and safety of interventional bronchus occlusions (IBO) using Amplatzer devices (ADs) in children with PAL secondary to SSP.

RESULTS

Six patients (four males, 4-15 years of age) underwent IBO using ADs as treatment for PAL. Necrotizing pneumonia (NP) was the most common cause (n=4) of PAL. Three patients were previously healthy and three suffered from chronic lung disease. All patients required at least two chest tubes prior to the intervention for a duration of 15-43 days and all required oxygen or higher level of ventilatory support. In three cases, previous surgical interventions had been performed without success. All children improved after endobronchial intervention and we observed no associated complications. All chest tubes were removed within 5-25 days post IBO. In patients with PAL related to NP (n=4), occluders were removed bronchoscopically without re-occurrence of pneumothorax after a mean of 70 days (IQR: 46.5-94).

CONCLUSION

IBO using ADs is a safe and valuable treatment option in children with PAL independent of disease severity and underlying cause. A major advantage of this procedure is its less invasiveness compared to surgery and the parenchyma- preserving approach.

Pediatric pneumothorax: Case studies and review of current literature

Pneumothorax is an abnormal collection of air between the lung and chest wall. Pneumothorax management guidelines put forth by the American College of Chest Physicians, European Respiratory Society, and British Thoracic Society are specific to adult patients. These guidelines' utility has not been addressed in pediatric populations, which causes significant management variation in younger patients. Additionally, pneumothorax management ranges from conservative to surgical treatment, but these approaches, timelines, and effectiveness have not been validated in significant numbers of pediatric patients. Here, we present three cases of pediatric pneumothorax with variable clinical courses—one with persistent air leak despite chest tube presence who underwent VATS and surgical resection of apical blebs. In contrast, the other two cases were managed more conservatively. We reviewed the current literature for diagnostic and management of pediatric patients with pneumothorax, which underscores the need for guidelines specific to this population.

Optimal treatment of pneumothorax in adolescents with Marfan syndrome

PURPOSE

Pneumothorax often develops in patients with Marfan syndrome (MFS). Here, we examined the effects of conservative and surgical pneumothorax treatments in children with MFS.

METHODS

In this study, 23 patients, less than 20 years old, diagnosed with both MFS and pneumothorax between 1999 and 2019 were included. All data were collected retrospectively from patients' medical records.

RESULTS

In total, 18 of 23 patients (78%) had relapsed pneumothorax either on the ipsilateral or contralateral side. Among these 18 patients, 6 (26%) patients had multiple relapses. Conservative and surgical treatments of pneumothorax were attempted in 33 and 29 lungs, respectively. The conservative treatment was attempted as a definitive therapy in 21 lungs. Twelve conservative treatments (57%) failed, which required surgical intervention. In 9 lungs (43%) with successful conservative treatment, 6 (67%) had ipsilateral relapses. In contrast to the above findings, only 4 (13%) ipsilateral relapses were observed in 29 surgical treatments.

CONCLUSIONS

Our study revealed a low response and high relapse rate when MFS adolescents who diagnosed pneumothorax were subjected to the conservative treatment modality. Thus, we recommend surgical intervention as the first line of therapy to treat pneumothorax in adolescents diagnosed with MFS.

LEVEL OF EVIDENCE

Ⅲ (Treatment Study).

An evidence-based review of primary spontaneous pneumothorax in the adolescent population

Primary spontaneous pneumothorax (PSP) is a relatively common problem in emergency medicine. The incidence of PSP peaks in adolescence and is most common in tall, thin males. Recent advances in the care of patients with PSP have called into question traditional approaches to management. This clinical review highlights the changing management strategies for PSP and concludes with a proposed evidence-based pathway to guide the care of adolescents with PSP.

Primary spontaneous pneumothorax in children: A single institutional experience

BACKGROUND

The treatment of primary spontaneous pneumothorax (PSP) remains controversial. We aimed to examine the role of chest computed tomography (CT), the advantages of pigtail catheter versus chest tube regarding duration of drainage or hospitalization period, and the impact of small PSP and surgical treatment on recurrence rate.

METHODS

We retrospectively reviewed the medical records of 109 children with PSP (20 years' period). Patients with recurrent and those with non-recurrent PSP were compared.

RESULTS

We recorded 183 episodes of PSP (45% recurrences), 89 patients (97%) were male, and the median age at presentation was 16 years. There were no significant differences between recurrence and non-recurrence PSP regarding age, gender, medical background, presentation symptoms, type of chest drain, median hospitalization length and median follow-up period. Recurrences were less frequent among patients who presented with small PSP and were treated conservatively (P = 0.029). PSP was almost always unilateral and the recurrence was observed ipsilateral in almost 80% of the cases. CT was more frequently used and blebs/bullae were more frequently found among patients with recurrent PSP. Pigtail use had no advantage in reducing hospitalization period and surgical procedures prevented recurrences.

CONCLUSION

The size of pneumothorax at presentation helps to predict recurrences. There are no differences regarding duration of drainage or hospitalization period in the use of pigtail compared to chest tube. CT helps evaluate findings in the lungs in recurrent cases of PSP and surgery prevents recurrences effectively.

Improving care through standardized treatment of spontaneous pneumothorax

PURPOSE

The objective of this quality improvement (QI) initiative was to implement a standardized clinical treatment protocol for patients presenting with primary spontaneous pneumothorax (PSP) in order to decrease hospital length of stay (LOS), diagnostic radiation exposure, and related cost.

METHODS

Baseline data from patients admitted with PSP from January 1, 2016 to July 31, 2018 were compared to data from patients managed using a newly developed evidence-based treatment pathway from August 1, 2018 to December 31, 2019. Standard QI methodology was used to track results.

RESULTS

Fifty-six episodes of PSP were observed during the baseline period and 40 episodes of PSP following initiation of the PSP protocol. The average LOS decreased from 4.5 days to 2.9 days. Patients underwent an average of 8.8 X-rays per admission preintervention versus 5.9 postintervention. The rate of CT scans decreased from 45% to 15% (p = 0.002). There was no significant difference in the rates of 30-day recurrence between the preintervention (13%) and postintervention (10%) groups (p = 0.7). Average admission costs per patient decreased by $1322 after adoption of the pathway.

CONCLUSIONS

Adoption of a standardized treatment protocol for PSP led to a reduction in LOS, diagnostic imaging utilization, and cost without increasing clinical recurrence.

TYPE OF STUDY

Quality improvement.

LEVEL OF EVIDENCE

Level III.

Primary Spontaneous Pneumothorax in Typhoid

We report a rare case of a 12-year-old girl who presented with a short history of diarrhea, vomiting and fever after traveling to Pakistan. During the course of initial investigations, her chest radiograph showed a primary spontaneous pneumothorax. There was no previous history of pulmonary disease. She was diagnosed as having Salmonella Typhi based on positive blood cultures. In the literature, spontaneous pneumothorax has been associated with typhoid fever as a complication of the disease in the pre-antibiotic era. However, a spontaneous pneumothorax associated with typhoid fever has never been reported to our knowledge in the post-antibiotic era.

Analysis of Pneumothorax in Noninvasive Ventilator Users With Duchenne Muscular Dystrophy

BACKGROUND

With the advancement of cardiorespiratory interventions, the survival rate among patients with Duchenne muscular dystrophy (DMD) has increased. Subsequently, pneumothorax has become a significant problem in patients with prolonged ventilatory support.

RESEARCH QUESTION

What are the frequency, recurrence rate, risk factors, and prognosis of pneumothorax in patients with DMD requiring noninvasive ventilation (NIV)? Also, are there known risk factors of pneumothorax on chest CT scans?

STUDY DESIGN AND METHODS

This retrospective longitudinal cohort study included 176 patients treated between 2006 and 2019. We collected information regarding location, severity, treatment methods, recurrence frequency, abnormal findings on CT scanning, and date of death. We compared the pneumothorax and nonpneumothorax groups. We calculated the estimated survival probabilities from the age at NIV application according to pneumothorax occurrence.

RESULTS

Sixteen of the 176 patients (9.0%) experienced pneumothorax (median age at diagnosis, 24.6 years; range, 20.7-33.7 years). Among the 16 patients, 15 demonstrated pneumothorax after NIV application (median time between diagnosis and initial NIV application, 5.6 years; range, 3 days-9.6 years). Sixteen patients experienced 31 episodes of pneumothoraces (range, one-five episodes); among them, seven episodes (22.6%) were asymptomatic. Known risk factors not clearly visible by radiography scans were found in chest CT scan in 11 patients (68.8%). Seven of 16 patients (43.8%) eventually sustained severe lung damage with pulmonary fibrosis. No significant between-group differences were found in body weight, BMI, and age at NIV application; however, the pneumothorax group showed a significantly higher mortality rate after NIV application.

INTERPRETATION

On pneumothorax occurrence in patients with DMD, recurrences and severe lung damage are common; moreover, these patients show higher mortality rates than patients without pneumothorax. Chest CT scans should be performed to identify risk factors, and treatment should be initiated accordingly. In addition, physicians should consider chest CT scanning in the case of suspected pneumothorax, even if no radiographic abnormality is found.

The results and outcome of primary spontaneous pneumothorax in adolescents

AIM

Primary spontaneous pneumothorax (PSP) is a rare pulmonary pathology that occurs in the absence of known lung disease. A retrospective study was performed to evaluate the results and outcome of PSP treatment in adolescents.

METHODS

The cases with PSP from January 2004 to December 2017 were evaluated for age, sex, family and smoking history, clinical and radiological findings and results of treatment.

RESULTS

Ten cases with PSP were included. The mean age of the patients was 15 years (10-17 years) and the male to female ratio was 9:1. Two of the patients (20%) had family history of PSP and four cases (40%) had smoking history. The initial complaints were chest pain (n=8), acute onset of cough (n=1) and breathing difficulty (n=1). Tube thoracostomy was performed in nine cases in which three of them were bilateral. Chest computed tomography (CT) demonstrated bullae (n=4; 40%) and subpleural blebs (n=2; 20%). Pleurodesis with talc was performed in four patients with pneumothorax for longer than a week in follow-up (n=4; 40%). Five cases had recurrent PSP within one year (n=5; 50%) and underwent pleurodesis with talc (n=4), autologous-blood (n=1) and bleomycin (n=1). Bleb excision was performed in two cases with persistent pneumothorax despite pleurodesis.

CONCLUSION

Tube thoracostomy and oxygen supplementation, are considered as initial and adequate treatment of PSP in most of the adolescents. Prolonged air leaks require pleurosdesis as the first line treatment and surgical excision of blebs should be reversed for the patients who are unresponsive to other treatment options.

Thoracoscopic Resection in the Treatment of Spontaneous Pneumothorax

Objectives:

We retrospectively evaluated the patients with primer spontaneous pneumothorax (PSP) who were treated with thoracoscopic resection.

Methods:

We retrospectively collected the data of the patients with a spontaneous pneumothorax who were operated with video-assisted thoracoscopic surgery (VATS) between 2010 and 2016.

Results:

During the study period, 10 patients applied to our hospital with spontaneous pneumothorax. Five children (three boys, two girls) with a mean age of 16.6 (16-17) were selected with VATS. Three of the patients had bleb, one of the patients had Congenital Cystic Adenomatoid Malformation (CCAM) type 2, and the last one had chronic emphysematous tissue on pathological analyses. Post-operative follow-up time was 2.2 (1-4) years without any complication.

Conclusion:

Spontaneous pneumothorax is a disease especially seen in puberty. The main reasons are apical segment bullae formation and blebs. VATS is especially advantageous to reach apical segments and for easy resections. Blebs, CCAM and emphysematous lung tissue may cause spontaneous pneumothorax.

A novel dual-covering method in video-assisted thoracic surgery for pediatric primary spontaneous pneumothorax

BACKGROUND

Primary spontaneous pneumothorax (PSP) generally occurs in young adults, whereas pediatric PSP is uncommon. It is difficult to source reliable data on pediatric PSP, the management of which is based on guidelines for adult PSP; however, the rate of recurrence after video-assisted thoracoscopic surgery (VATS) for pediatric PSP is reported to be higher.

METHODS

We reviewed retrospectively a collective total of 66 surgical cases of a first pneumothorax episode in 46 children under 16 years of age, who were treated at our hospital between February, 2005 and November, 2017.

RESULTS

The surgical cases were divided into two groups, depending on how the treated lesions were covered. In the dual-covering (DC) group, the PSP was covered by oxidized regenerated cellulose and polyglycolic acid (8 patients; 13 cases) and in the single-covering (SC) group, the PSP was covered by oxidized regenerated cellulose (38 patients; 53 cases). There was no incidence of recurrence after surgery in the DC group, but 17 cases (32.1%) of recurrence after surgery in the SC group. This difference was significant.

CONCLUSION

The DC method prevented the recurrence of PSP more effectively than the SC method after VATS in pediatric patients. Long-term follow-up after VATS for pediatric PSP is also important because of the risk of delayed recurrence.

The influence of pleurodesis on the outcome of primary spontaneous pneumothorax in children

BACKGROUND

Primary spontaneous pneumothorax (PSP) has a high rate of recurrence, and pleurodesis has been shown to decrease the rate of recurrence in adult PSP. For pediatric PSP patients, there are only a few case series available and evidence on the benefits of pleurodesis is insufficient. This study aimed to analyze the outcome of pleurodesis among pediatric PSP patients via a nationwide population-based cohort in Taiwan.

METHODS

The hospitalization data from the pediatric intensive care sampling file of the National Health Insurance Research Database from January 1 to December 31, 2010, were retrieved and analyzed. Children aged 0-18 years with a discharge diagnosis of PSP (ICD-9: 512, 512.0, and 512.8) were enrolled in the study. Demographic data, management strategies, and clinical outcomes were recorded and analyzed as well.

RESULTS

A total of 1005 hospitalization cases were identified and divided into the pleurodesis (409 hospitalizations) and nonpleurodesis (596 hospitalizations) groups. In the univariate analysis, thoracoscopic surgery for PSP decreased the incidence of recurrence (hazard ratio [HR], 0.46; 95% CI, 0.32-0.67) and the need for further surgical intervention (HR, 0.29; 95% CI, 0.18-0.47); however, conventional open surgery did not. A lesser incidence of PSP recurrence (HR, 0.53; 95% CI, 0.37-0.78) and fewer subsequent surgical interventions (HR, 0.32; 95% CI, 0.20-0.52) were found in the pleurodesis group in comparison with the nonpleurodesis group. A multivariate Cox regression analysis revealed that pleurodesis was the only significant factor capable of decreasing the incidence of PSP recurrence (HR, 0.57; 95% CI, 0.38-0.86) and the need for further surgical intervention (HR, 0.40; 95% CI, 0.23-0.69).

CONCLUSION

Pleurodesis reduces the rate of recurrence and the need for further surgical intervention in pediatric PSP. It may be considered as the method of choice for the management of PSP in children.

Management and recurrence of spontaneous pneumothorax in children

Objective

No guideline clearly prescribes an approach to management of spontaneous pneumothorax in children. The objectives of this study were to evaluate practice variation in the management of spontaneous pneumothorax in children and its probability of recurrence.

Methods

This study was a retrospective chart review followed by a phone follow-up that included all children who had visited a tertiary care paediatric hospital for a first episode of spontaneous pneumothorax between 2008 and 2017. The primary outcomes were the management of pneumothorax (observation, oxygen, needle aspiration, intercostal chest tube, surgery) and the probability of recurrence. All charts were evaluated by a rater using a standardized report form and 10% of the charts were evaluated in duplicate. All children/families were contacted by phone to assess recurrence. The primary analyses were the proportions of each treatment modalities and recurrence, respectively.

Results

During the study period, 76 children were deemed eligible for the study. Among them, 59 had a primary spontaneous pneumothorax while 17 were secondary. The most common first therapeutic approaches were chest tube insertion (31), oxygen alone (27), and observation (14). A total of 54 patients were available for follow-up among whom a recurrence was observed in 28 (37% of the total cohort or 52% of available children).

Conclusion

Chest tube insertion was the first line of treatment in about 40% of children with a first spontaneous pneumothorax. In this population, the recurrence probability is established between 37 and 52% and the majority occurs in the following months.

Current Practice in the Management of Spontaneous Pneumothorax in Children

INTRODUCTION

There is a lack of pediatric-specific guidelines for the workup and management of primary spontaneous pneumothorax (PSP) in children. The aim of this study was to describe current practices among North American pediatric surgeons.

MATERIALS AND METHODS

An online survey comprising 18 questions was sent out through the American Pediatric Surgical Association Outcomes and Clinical Trials Committee to all members. Bivariate analysis was performed using Chi-square analysis.

RESULTS

A total of 287 surveys were completed (33% response rate). For a first episode of PSP, 57% of surgeons opt for chest tube drainage, 4% for upfront video-assisted thoracoscopic surgery (VATS), 3% for needle aspiration, and 29% for only oxygen administration. Eighty-one percent of surgeons report that the size of the pneumothorax influences management. However, neither practice setting (P = .87) nor years in practice (P = .11) correlated with initial management strategy. For patients with a persistent air leak after chest tube placement, there is wide variation in duration of observation before performing VATS, with 40% operating after 3 days, but 21% waiting at least 5 days. The use of chest computed tomography (CT) is also highly variable. Eighty-two percent of respondents perform surgery only after the second episode of PSP. Most perform a stapled apical blebectomy and mechanical pleurodesis for both initial and recurrent PSP.

CONCLUSION

There is significant variation among pediatric surgeons in the management of spontaneous pneumothorax, including the use of CT, timing of operation, and duration of observation for air leak before performing surgery. Prospective data are needed to better inform guidelines and standardize practice.

Spontaneous Pneumoperitoneum in Pediatric Patients: Dilemmas in Management

Context:

Pneumoperitoneum is typically a surgical emergency, particularly in neonates. However, pneumoperitoneum can rarely present without gastrointestinal perforation which is known as spontaneous pneumoperitoneum.

Aims:

This study aims to analyze the outcome of pediatric patients with spontaneous pneumoperitoneum and describe our experience.

Settings and Design:

A retrospective study performed from January 2014 to May 2017.

Materials and Methods:

The study included all pediatric patients admitted in a tertiary care institute.

Results:

There were 9 patients with 5 males and 4 females, out of which 7 were neonates. At presentation, respiratory distress was a common complaint (8/9). 5 out of all patients developed abdominal distension. Associated malformations were seen in 5 patients. Pneumoperitoneum was preceded by mechanical ventilation in 5 patients. Abdominal examination revealed soft distension with relaxed abdominal wall in 7, while marked distension was present in 2 cases. Features suggestive of peritonitis were absent in all the patients. Abdominal radiographs revealed free air in all, while, radiographic evidence of pneumothorax was seen in 2 patients. Conservative management without any operative intervention was performed in 3 patients with favorable outcome. Laparotomy was performed in 1 patient; negative for any perforation and outcome was unfavorable. In 5 patients, abdominocentesis was performed followed by abdominal drain placement. No patient had any evidence of leakage of intestinal contents from gastrointestinal tract after insertion of abdominal drain. Favorable outcome was present in 5 patients. Out of 4 cases with unfavorable outcome, 3 patients were having esophageal atresia.

Conclusions:

A high index of suspicion for spontaneous pneumoperitoneum must be present when dealing with pediatric patients, especially neonates with pneumoperitoneum and without clinical signs of peritonitis. A comprehensive clinical evaluation with sepsis screen must be carried out to supplement the diagnosis. Pneumoperitoneum in pediatric patients, especially neonates, is not always an absolute indication for surgery.

Thoracoscopic Management of Blebs: Resection With/Out Primary Pleurodesis

OBJECTIVES

To review the literature for justification of thoracoscopic management of blebs in children.

METHODS

PubMed database was reviewed for articles in English, Portuguese and Spanish using the key words "thoracoscopy", "bleb" and "child". Data was collected for age, gender, type of surgery performed, operating time, conversions, complications, recurrences, follow-up and mortality.

RESULTS

Eleven studies with total 266 patients were included (27 bilateral cases; n = 293 surgeries). Median age was 15.7 y (range 11-18 y), 225 were male (87.9%) and 31 were female (12.1%) patients. Endo GIA™ was used in 10 cases, Endoloop® in 11 surgeries, unspecified stapler devices in 150 procedures and, in 122 surgeries, instruments were not mentioned. Pleurodesis was performed in 213 (72.7%) cases. There were 5 (1.7%) conversions (adhesions n = 3, bleeding n = 1, camera failure n = 1). Complications were documented in 8 (2.7%): pneumothorax after chest tube removal 4 (drain reinsertion n = 3, reoperation n = 1); prolonged air leak 3, all submitted to che pleurodesis; bleeding requiring reoperation 1. Recurrence occurred in 25 (8.5%): 10 re-operation, 7 conservative management, 2 chemical pleurodesis, 2 chest tube reinsertions and in 4 the management was not specified. The median follow-up was 46.1 mo (range 3 mo-11 y). There were no lethal outcomes.

CONCLUSIONS

Although data is scarce on specific instruments used, pleurodesis is performed in 70% of cases. Irrespective of this, thoracoscopic resection of blebs can be safely offered as it has a low complication and conversion rates and no mortality.

The use of perioperative ketorolac in the surgical treatment of pediatric spontaneous pneumothorax

BACKGROUND

We sought to determine the effect of ketorolac on pediatric primary spontaneous pneumothorax recurrence after operation.

METHODS

The Pediatric Health Information System database was queried for patients ages 10-16years discharged in the years 2004-2014 with pneumothorax or pleural bleb and a related operative procedure. Deaths and secondary pneumothorax were excluded. Variables included demographics, chronic disease, intensive care unit admission, mechanical ventilation, and lung resection or plication. The primary variable was any ketorolac administration between post-operative day 0 and 5. Outcomes included reintervention within 1year, readmission, post-operative length of stay (LOS), and cost. Bivariate and multivariate logistic regression analyses were performed.

RESULTS

Of 1678 records that met inclusion criteria, 395 (23%) were subsequently excluded, leaving 1283 patients for analysis. Most patients had a lung resection recorded (78%) and the majority were administered ketorolac (57%); few required reintervention (20%) or readmission (18%). Mean postoperative LOS was 5.2±3.8days and mean cost was $17,649±$10,599. On bivariate analysis, ketorolac administration did not correlate with any measured outcome. On both bivariate and multivariate analysis, no variable was predictive of reintervention, and only lung resection correlated with readmission (adjusted odds ratio 0.63 [95% C.I. 0.45-0.90]).

CONCLUSION

Post-operative ketorolac administration was not associated with an increased likelihood of reintervention or readmission within 1year of operative treatment of primary spontaneous pneumothorax, suggesting that it may be used safely as part of a post-operative pain control regimen. Effects on postoperative length of stay and cost, however, were not demonstrated.

LEVEL OF EVIDENCE AND TYPE OF STUDY

Level III treatment study.

An Age-Stratified Longitudinal Study of Primary Spontaneous Pneumothorax

PURPOSE

The objective of this study was to determine the age-stratified incidence, frequency, and duration of recurrence of primary spontaneous pneumothorax (PSP).

METHODS

This study analyzed the epidemiology of PSP among hospitalized patients using the National Health Research Institutes of Taiwan database. The incidence of PSP was determined from a cohort of 19,562 deidentified individuals with PSP between 2001 and 2013. The insurants consisted of 99% of the Taiwan population of about 23 million people. A 5- to 12-year long-term recurrence analysis was based on data from 11,190 patients with PSP between 2001 and 2008.

RESULTS

The incidence of PSP in in-patients increased from 5.05 to 7.18/100,000 in a 13-year analysis. The age group at highest risk was 15-22 years with incidence rates >11/100,000 and readmission rates of 17%-31%. About 20% of patients had more than one attack based on long-term follow-ups. About .8% of patients had more than three hospital admissions. Only 3.9% of patients had repeated or recurrent attacks after more than 4 years. All patients who had been admitted on more than four occasions were adolescents, except for four patients who were aged between 20 and 24 years old.

CONCLUSIONS

Adolescents with PSP had a higher incidence of attacks and more frequent and longer periods of vulnerability to recurrence. The majority of patients experienced recurrence during the first 4 years after the first attack.

Postoperative Pulmonary Complications Following Laparoscopy

Postoperative pulmonary complications (PPCs) unrelated to anesthesia, especially hydropneumothorax, are rare after gynecologic laparoscopy. Hydropneumothorax can cause respiratory failure and be life-threatening, however. Awareness, prompt diagnosis, and timely intervention are crucial for clinical management. We review the literature for PPCs, including pneumothorax, hydrothorax, hydropneumothorax, and pleural effusion following laparoscopy, and also present a recent case of hydropneumothorax seen at our institution.

Surgical Intervention for Primary Spontaneous Pneumothorax in Pediatric Population: When and Why?

INTRODUCTION

Spontaneous pneumothorax in pediatric patients is relatively uncommon. The management strategy varies in different centers due to dearth of evidence-based pediatric guidelines. In this study, we reviewed our experience of thoracoscopic management of primary spontaneous pneumothorax (PSP) in children and identified risk factors associated with postoperative air leakage and recurrence.

MATERIALS AND METHODS

We performed a retrospective analysis of pediatric patients who had PSP and underwent surgical management in our institution between April 2008 and March 2015. Demographic data, radiological findings, interventions, and surgical outcomes were analyzed.

RESULTS

A total of 92 patients with 110 thoracoscopic surgery for PSP were identified. The indications for surgery were failed nonoperative management with persistent air leakage in 32.7%, recurrent ipsilateral pneumothorax in 36.4%, first contralateral pneumothorax in 14.5%, bilateral pneumothorax in 10%, and significant hemopneumothorax in 5.5%. Bulla was identified in 101 thoracoscopy (91.8%) with stapled bullectomy performed. 14.5% patients had persistent postoperative air leakage and treated with reinsertion of thoracostomy tube and chemical pleurodesis. 17.3% patients had postoperative recurrence occurred at mean time of 11 months. Operation within 7 days of symptoms onset was associated with less postoperative air leakage (P = .04). Bilateral pneumothorax and those with abnormal radiographic features had significantly more postoperative air leakage (P = .002, P < .01 respectively) and recurrence (P < .01, P = .007).

CONCLUSION

Early thoracoscopic mechanical pleurodesis and stapled bullectomy after thoracostomy tube insertion could be offered as a primary option for management of large PSP in pediatric population, since most of these patients had bulla identified as the culprit of the disease.

Video-assisted thoracoscopic treatment of primary spontaneous pneumothorax in older children and adolescents

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a relatively rare condition in the pediatric population lacking of specific recommendations regarding the management. Video-assisted thoracoscopic surgery (VATS) has gained widespread consensus during the last 10 years. We retrospectively reviewed our experience of VATS in the treatment of pediatric patients affected by PSP in terms of timing of surgery, operative technique, and postoperative outcome.

METHODS

Between 1998 and 2014, 58 pediatric patients were treated for PSP. Treatment consisted in pulmonary apicectomy in all patients and pleurodesis. Patients received either apical pleurectomy and mechanical pleurodesis or mechanical pleurodesis alone.

RESULTS

Mean age was 16.6 ± 1.6 years (range 10-18) with a male/female ratio of 5:1. Seventeen patients underwent surgery after the first episode of PSP. Apical pleurectomy and mechanical pleurodesis was performed in 30 patients while others received mechanical pleurodesis alone. Conversion to open surgery was needed in four procedures (6.9%). Postoperative complications occurred in 1.7% of cases. Sixteen patients received more than one procedure for contralateral pneumothorax (15 cases) and postoperative recurrence (1 case). The mean follow-up was 95 ± 63 months. Recurrence rate was 12.1%. Univariate analysis showed that recurrence was significantly correlated with younger age (P = 0.044) and postoperative chest tube (P = 0.027). Both univariate and multivariate analysis showed that apical pleurectomy did not prevent recurrences.

CONCLUSIONS

VATS is an effective procedure for PSP in pediatric patients. Apical pleurectomy does not seem to prevent recurrence. Due to the increased risk of recurrence of PSP in younger patients, indication to VATS after the first episode might be considered. Pediatr Pulmonol. 2016;51:713-716. © 2016 Wiley Periodicals, Inc.

The efficacy and economical benefits of blood patch pleurodesis in secondary spontaneous pneumothorax patients

INTRODUCTION

Prolonged air leak in secondary spontaneous pneumothorax (SSP) patients remains one of the biggest challenges for thoracic surgeons. This study investigates the feasibility, effectiveness, clinical outcomes, and economical benefits of the autologous blood patch pleurodesis method in SSP.

MATERIAL AND METHODS

First-episode SSP patients undergoing autologous blood patch pleurodesis for resistant air leak following underwater-seal thoracostomy, between January 2010 and June 2013 were taken into the study. Timing and success rate of pleurodesis, recurrence, additional intervention, hospital length of stay, and complications that occurred during follow-up were examined from medical records, retrospectively.

RESULTS

Thirty-one (27 male, 4 female) SSP patients with expanded lungs on chest X-ray and resistant air leak on the 3(rd) post-interventional day were enrolled. Mean age was 53.7 ± 18.9 years (range: 23-81). Twenty-four patients were treated with tube thoracostomy, 2 with pezzer drain, and 5 with 8 F pleural catheter. 96.8% success was achieved; air leak in 29 of 31 patients (93.5%) ceased within the first 24 hours. No procedure-related complication such as fever, pain or empyema was seen. Late pneumothorax recurrence occurred in 4 (12.9%) patients; 1 treated with talc pleurodesis where the other 3 necessitated surgical intervention.

CONCLUSIONS

Autologous blood patch pleurodesis is a safe, effective, and easily performed procedure with no need of any additional equipment or extra cost. This method can be applied to all patients with radiologically expanded lungs and continuous air leak after 48 hours following water-seal drainage thoracostomy, to reduce hospital stay duration, unnecessary surgical interventions, and the expenses.

Management of paediatric spontaneous pneumothorax: a multicentre retrospective case series

OBJECTIVES

Paediatric guidelines are lacking for management of spontaneous pneumothorax. Adult patient-focused guidelines (British Thoracic Society 2003 and 2010) introduced aspiration as first-line intervention for primary spontaneous pneumothorax (PSP) and small secondary spontaneous pneumothoraces (SSP). Paediatric practice is unclear, and evidence for aspiration success rates is urgently required to develop paediatric-specific recommendations.

METHODS

Retrospective analysis of PSP and SSP management at nine paediatric emergency departments across Australia and New Zealand (2003-2010) to compare PSP and SSP management.

RESULTS

219 episodes of spontaneous pneumothorax occurred in 162 children (median age 15 years, 71% male); 155 PSP episodes in 120 children and 64 SSP episodes in 42 children. Intervention in PSP vs SSP episodes occurred in 55% (95% CI 47% to 62%) vs 70% (60% to 79%), p<0.05. An intercostal chest catheter (ICC) was used in 104/219 (47%) episodes. Aspiration was used in more PSP than in SSP episodes with interventions (27% (18% to 37%) vs 9% (3% to 21%), p<0.05). Aspiration success was 52% (33% to 70%) overall and not significantly different between PSP and SSP. Aspiration success was greater in small vs large pneumothoraces (80% (48% to 95%) vs 33% (14% to 61%), p=0.01). Small-bore ICCs were used in 40% of ICCs and usage increased during the study.

CONCLUSIONS

In this descriptive study of pneumothorax management, PSP and SSP management did not differ and ICC insertion was the continuing preferred intervention. Overall success of aspiration was lower than reported results for adults, although success was greater for small than for large pneumothoraces. Paediatric prospective studies are urgently required to determine optimal paediatric interventional management strategies.

Surgical management for complications of pediatric lung injury

The etiologies of pediatric lung injury requiring surgical intervention can be infectious, traumatic, congenital, or iatrogenic. Childhood pneumonia is a significant global health problem affecting 150 million children worldwide. Sequelae of pulmonary infections potentially requiring surgery include bronchiectasis, lung abscess, pneumatocele, and empyema. Trauma, congenital conditions such as cystic fibrosis and iatrogenic injuries can result in pneumothoraces, chylothoraces, or bronchopleural fistulae. Recurrence rates for spontaneous pneumothorax treated non-operatively in pediatric patients approach 50-60%. Chylothoraces in newborns may occur spontaneously or due to birth trauma, whereas in older children the etiology is almost always iatrogenic. This article examines the surgical management for the complications of lung injury in pediatric patients. In addition, we review the available pediatric evidence for early tracheostomy as well as treatment strategies for the negative ramifications of tracheostomy.

Factors associated with proceeding to surgical intervention and recurrence of primary spontaneous pneumothorax in adolescent patients

Primary spontaneous pneumothorax (PSP) is not uncommon, and its recurrence is often a challenging clinical problem. Surgical management and predisposing factors for the recurrence of PSP, however, have not yet been well elucidated in adolescent patients. The major aim of this study was to investigate factors associated with proceeding to surgical intervention and recurrence of PSP in adolescents. Two hundred and nineteen episodes of PSP in 171 adolescent patients were retrospectively reviewed. The clinical and radiological spectrum of PSP and factors for proceeding to surgical intervention were assessed in these 171 patients. Risk factors for the recurrence of PSP were further analyzed in 128 patients with first attack of PSP. The male-to-female ratio of the 171 PSP patients was 9:1, and the mean age was 17.6 ± 1.5 years. The median body mass index (BMI) percentile was 11 (range 2-31), and 45 (34 %) patients had underweight BMI. The incidence of recurrent PSP was high with a total recurrence rate of 21 %. Ipsilateral recurrence rate of PSP after video-assisted thoracoscopic surgery (VATS) was much less than that of the conservative treatment (4 vs. 18 %). A large-size pneumothorax with a persistent air leak was the most significant factor for proceeding to VATS surgery (P = 0.001). In addition, it was a significant factor influencing the recurrence of PSP (P = 0.014). Other factors that did not significantly affect the recurrence rate were BMI, smoking status, and the number of bullae.

CONCLUSION

Adolescent PSP has a high recurrence rate of 21 % after a 2-year follow-up. A large-size pneumothorax with a persistent air leak may not only lead to surgical intervention but also the risk of a recurrence of PSP. The initial size of pneumothorax may not only guide the management process but also predict the risk of a recurrence in adolescent patients with PSP.

Spontaneous pneumothorax as indicator for Birt-Hogg-Dubé syndrome in paediatric patients

Background

Birt-Hogg-Dubé syndrome (BHD) is a rare autosomal dominantly inherited disorder caused by germline mutations in the folliculin (FLCN) gene. Clinical manifestations of BHD include skin fibrofolliculomas, renal cell cancer, lung cysts and (recurrent) spontaneous pneumothorax (SP). All clinical manifestations usually present in adults > 20 years of age.

Case presentations

Two non-related patients with (recurrent) pneumothorax starting at age 14 accompanied by multiple basal lung cysts on thoracic CT underwent FLCN germline mutation analysis. A pathogenic FLCN mutation was found in both patients confirming suspected BHD. The family history was negative for spontaneous pneumothorax in both families.

Conclusion

Although childhood occurrence of SP in BHD is rare, these two cases illustrate that BHD should be considered as cause of SP in children.

Reexpansion pulmonary edema: review of pediatric cases

Reexpansion pulmonary edema (RPE) is an increased permeability pulmonary edema that usually occurs in the reexpanded lung after several days of lung collapse. This condition is recognized to occur more frequently in patients under the age of 40 years, but there has been no detailed analysis of reported pediatric cases of RPE to date. For this review, PubMed literature searches were performed using the following terms: 're(-)expansion pulmonary (o)edema' AND ('child' OR 'children' OR 'infant' OR 'boy' OR 'girl' OR 'adolescent'). The 22 pediatric cases of RPE identified were included in this review. RPE was reported in almost the entire pediatric age range, and as in adult cases, the severity ranged from subclinical to lethal. No specific treatment for RPE was identified, and treatment was administered according to the clinical features of each patient. Of the 22 reported cases, 10 occurred during the perioperative period, but were not related to any specific surgical procedures or anesthetic techniques, or to the duration of lung collapse. Pediatric anesthesiologists should be aware that pediatric RPE can occur after reexpansion of any collapsed lung and that some invasive therapies can be useful in severe cases.

What factors predict recurrence after an initial episode of primary spontaneous pneumothorax in children?

PURPOSE

Recurrence is the most common complication after an initial episode of primary spontaneous pneumothorax (PSP). However, preventive surgery in children remains a controversial issue. The purpose of this study was to determine predictive factors of recurrence to better inform early surgical referrals.

METHODS

We retrospectively reviewed all consecutive patients under 18 years of age who conservatively treated for an initial episode of PSP between March 2005 and September 2011.

RESULTS

One hundred fourteen patients were included in this study. The mean follow-up period was 43.1 months. Ipsilateral and contralateral recurrence developed in 47.3% and 14.0% of patients. The risk of ipsilateral recurrence for patients with or without air-containing lesions according to high-resolution computed tomography (HRCT) was 60.3% and 31.4%. In the multivariate analysis, the presence of air-containing lesions on HRCT scans and bullae on chest X-rays were independent risk factors for ipsilateral recurrence.

CONCLUSION

The presence of bleb or bullae on HRCT scans or chest X-rays after an initial episode of PSP was significantly related to the ipsilateral recurrence in children. If the risk factors are clarified in further studies, hospital stays and the recurrence of PSP after the first episode could be reduced with early video-assisted thoracoscopic surgery.