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

  • Abigail J. Engwall-Gill
    Correspondence
    Corresponding author.
    Affiliations
    Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287-1005, USA
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  • Jennine H. Weller
    Affiliations
    Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287-1005, USA
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  • Simon Rahal
    Affiliations
    Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287-1005, USA
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  • Eric Etchill
    Affiliations
    Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287-1005, USA
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  • Shaun M. Kunisaki
    Affiliations
    Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287-1005, USA
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  • Isam W. Nasr
    Affiliations
    Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287-1005, USA
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      Highlights

      • Primary spontaneous pneumothorax (PSP) is rare with an incidence of 3.4 per 100,000 children.
      • There is no consensus on pediatric PSP management guidelines.
      • Video-assisted thoracoscopic surgery (VATS) after chest tube decompression (CTD) was associated with a longer LOS and chest tube days.
      • Air leak and increase in pneumothorax size at 24 h after CTD were related to progression to VATS.
      • Air leak and increase in pneumothorax size were combined associated with a 6-fold increased risk of recurrence in a two-year period.

      Abstract

      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

      Keywords

      Abbreviations:

      PSP (primary spontaneous pneumothorax), PTX (pneumothorax), CTD (chest tube decompression), VATS (video-assisted thoracoscopic surgery), ACC (American College of Chest Physicians), BTS (British Thoracic Society), CXR (chest X-ray), CT (computed tomography), LOS (postoperative length of stay), ICD (international classification of diseases), IQR (interquartile range), IRR (incidence rate ratio)
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