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See also

Thoracocentesis and chest drain insertion

Key Points

1. The size of the pneumothorax is less important than the degree of clinical compromise, as this determines management
2. Severe symptoms and signs of respiratory distress suggest the presence of tension pneumothorax. Tension pneumothorax is a medical emergency and requires urgent needle thoracocentesis

Background

• Primary spontaneous pneumothorax (PSP) is a pneumothorax occurring in children 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 eg cystic fibrosis. Seek advice from a respiratory specialist or surgeon
• PSP recurrence rate is 30-40%, typically on the same side and within 1 year (median 2 months)

Assessment

History

• Acute onset chest pain: severe and/or stabbing pain, radiating to ipsilateral shoulder and increasing with inspiration (pleuritic), can subside over 24 hours despite a persistent pneumothorax
• Sudden shortness of breath
• Anxiety, cough and generalised symptoms (eg malaise, fatigue) are less common

Examination

• Children with a small pneumothorax may have a normal examination
• Tachycardia and tachypnoea
• Hyperresonance on percussion
• Ipsilateral decreased or absent air entry and decreased vocal fremitus
• Asymmetric lung expansion
• Mediastinal shift
• Consider transillumination in young infants

Tension Pneumothorax

• Deviation of the trachea to the contralateral side
• Tachycardia
• Hypotension
• Cyanosis

Tension pneumothorax is a medical emergency requiring urgent needle thoracocentesisÌý(see Thoracocentesis and chest drain insertion)

Management

Investigations

• Chest x-ray (CXR): 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 CXR 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
• Consider point of care US if available
• CT scan is not routinely recommended
• 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 >12 years 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 (a). If >3 cm, pneumothorax is large Ìý
  OR
  
• Measurement of the distance between the lateral lung edge and chest wall at the level of the hilum (b); >2 cm = (at least 50%)
  
  
  

Ìý

• For younger children, there is no validated method for measuring pneumothorax volume. The may be used Ìý

Treatment

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Consider consultation with local paediatric team when

All children with:

• Large pneumothorax
• Significant symptoms (significant breathlessness, pain or hypoxia)
• Age <12 years: may have less reliable reporting of symptoms and size calculations may not be applicable
• Secondary pneumothorax from underlying lung disease eg cystic fibrosis, chronic neonatal lung disease, asthma
• Trauma or thoracic surgery
• Positive pressure ventilation
• Foreign body inhalation
• Evidence of tension pneumothorax
• Recurrence

Consider transfer when

• Need for ongoing drainage or underwater seal drainage
• Deterioration during observation
• Child requires care above the level of comfort of local hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

• Minimal symptoms and no deterioration during period of observation
• Appropriate follow up arranged (24-48 hours)
• Appropriate education regarding recurrence rate and recognition of symptoms

Parent information

Last updated November 2023