Among children with primary spontaneous pneumothorax (PSP), conservative management is gaining traction in the absence of formal, widely-accepted clinical guidelines specifically for children. Moreover, real-world experience suggests that aspiration may be of limited use for this population, according to a review published recently in Paediatric Respiratory Reviews, which also includes a proposed management protocol for PSP based on recent research.
To date, the clinical approach to dealing with pediatric spontaneous pneumothorax has been to assume the children will respond like adults, so these patients receive treatment based primarily on adult experience and research conducted on adult patients. In 2009, the researchers of the current review suggested a treatment strategy of aspiration first, which agreed with international guidelines at that time. Subsequently, retrospective pediatric case studies were published specific to the pediatric PSP experience. Researchers of the current review therefore sought to re-evaluate recommendations for PSP treatment in the context of both recent studies and their own real-world experience.
To accomplish this, the researchers performed a review of recent research and also conducted a multicenter retrospective analysis and audit of the management of PSP cases at their own institution, Children’s Hospital at Westmead, Australia. The literature review found that over the past decade, data from 414 pediatric cases, which included 274 with PSP, suggest “that aspiration is not being commonly performed as a first line intervention, and when it is used it has a low rate of success (about 50%),” the investigators noted. The literature review also found that surgeons are “reluctant to perform operative therapy,” and that a questionnaire administered to surgeons indicated that only 4% used video-assisted thoracoscopic surgery as first-line treatment.
The literature review authors also cited a landmark multicenter noninferior randomized controlled trial (RCT) of 316 patients (14 to 50 years of age; approximately 15% pediatric) from 39 Australian and New Zealand centers with moderate-to-large PSP compared outcomes of intervention (ie, insertion of an intercostal chest catheter) vs conservative management (observation, medication to relieve pain, and oxygen therapy) in cohorts of 154 patients and 162 patients, respectively. The trial found that conservative management proved noninferior to intervention with respect to radiographic PSP resolution within 8 weeks (98.5% vs 94.4%; risk difference -4.1 percentage points, P =.02). The trial also found patients with conservative management had fewer serious adverse events (10% vs 32%, relative risk, 3.30) and lower recurrence rates (9% vs 17%, absolute risk difference, 8.0 percentage points).
The review authors also conducted a retrospective analysis of PSP and secondary spontaneous pneumothorax (SSP) patients at their own institution from 2009-2019. During this time, 65 patients presented with 84 cases (55 PSP, 29 SSP; 77% male; 12.5±4.7 years of age [range 4 weeks to 18 years]). PSP cases were left sided (80%) and large (58%), and half followed conservative management, with a quarter of these requiring subsequent intervention. The most common intervention was an intercostal chest catheter (89%). Aspiration was received by 13% of patients, with 57% (4/7) requiring subsequent intercostal chest catheter. In comparing conservative management to intervention, researchers found that conservative management had a lower incidence of large pneumothoraxes (26% vs 83%, P <.01), fewer adverse events (0% vs 20%, P =.02), a shorter length of hospital stay (2.1±1.7 vs 5.6±5.0 days, P <.01) but no difference in recurrence rates (15% vs 20%, P =.64).
Researchers concluded that although pediatric-specific guidelines have not been forthcoming, the increase in pediatric-specific evidence augmented by a landmark RCT study suggested 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.”
Lieu N, Ngo P, Chennapragada SM, et al. Update in management of pediatric primary spontaneous pneumothorax. Paediatr Respir Rev. 2022;41:73-79. doi:10.1016/j.prrv.2021.08.001