Overview
Definition:
Pneumothorax in children is the presence of air in the pleural space, leading to partial or complete lung collapse
Chest tube management, also known as tube thoracostomy or chest drainage, is a procedure to remove air (or fluid) from the pleural space and allow the lung to re-expand.
Epidemiology:
Incidence varies by cause, with spontaneous pneumothorax less common in children than adults
Secondary pneumothorax occurs due to underlying lung disease (e.g., asthma, cystic fibrosis, pneumonia, trauma) or iatrogenic causes (e.g., central line insertion, mechanical ventilation)
Idiopathic spontaneous pneumothorax is rare in children.
Clinical Significance:
Timely and appropriate chest tube management is crucial for relieving respiratory distress, preventing complications like tension pneumothorax, and facilitating lung re-expansion
Proper technique minimizes iatrogenic injuries and improves patient outcomes, essential for resident competence in DNB and NEET SS practice.
Clinical Presentation
Symptoms:
Sudden onset of respiratory distress
Tachypnea
Chest pain, often pleuritic
Cyanosis
Decreased activity
Cough
Grunting respirations.
Signs:
Tachycardia
Decreased breath sounds on the affected side
Hyperresonance to percussion on the affected side
Subcutaneous emphysema
Tracheal deviation (in tension pneumothorax)
Retractions
Nasal flaring
Accessory muscle use.
Diagnostic Criteria:
Diagnosis is primarily clinical and confirmed by imaging
Significant pneumothorax is often defined by the amount of pleural space occupied by air, though clinical presentation guides management urgency
Tension pneumothorax is a clinical diagnosis characterized by hemodynamic instability.
Diagnostic Approach
History Taking:
Detailed history of present illness, including onset, duration, and severity of symptoms
History of underlying lung disease, trauma, recent procedures (e.g., central venous catheterization, mechanical ventilation), or prior pneumothorax
Family history of respiratory conditions.
Physical Examination:
Complete cardiopulmonary examination
Assess respiratory rate, pattern, and effort
Palpate for subcutaneous emphysema
Auscultate for breath sounds, noting decreased or absent sounds on the affected side
Percuss for hyperresonance
Assess for tracheal deviation.
Investigations:
Chest X-ray (CXR) is the primary imaging modality, typically anteroposterior (AP) and lateral views
Lateral decubitus views can sometimes reveal small pneumothoraces
Ultrasound of the chest can also be useful for diagnosing pneumothorax, especially in unstable patients
CT scan of the chest is reserved for complex cases or to evaluate underlying lung pathology.
Differential Diagnosis:
Asthma exacerbation
Pneumonia
Pulmonary embolism
Congenital pulmonary airway malformation (CPAM)
Bronchiolitis
Diaphragmatic hernia
Foreign body aspiration
Cardiac tamponade.
Management
Initial Management:
Immediate assessment of airway, breathing, and circulation (ABC)
Supplemental oxygen to maintain adequate saturation
Pain management
Stabilize the patient, especially if hemodynamically unstable
Identify and address potential causes of pneumothorax.
Chest Tube Insertion:
Indications: Symptomatic pneumothorax, significant pneumothorax size, tension pneumothorax, mechanical ventilation, underlying lung disease
Contraindications: Relative contraindications include coagulopathy and severe infection at the insertion site
Procedure: Sterile technique is paramount
Local anesthesia
Incision at the mid-axillary line in the 4th or 5th intercostal space
Blunt dissection to the pleura
Insertion of appropriately sized chest tube (e.g., 8-16 Fr for neonates/infants, 16-28 Fr for older children, depending on size and indication)
Connect to a water-seal drainage system, potentially with suction
Secure tube
Obtain post-procedure CXR to confirm placement and lung re-expansion.
Drainage System Management:
Maintain patency of the chest tube and drainage system
Monitor for air leaks (bubbling in the water seal)
Ensure proper functioning of the water seal and suction
Record drainage output
Administer analgesia as needed
Clamp tube only when indicated and for short periods.
Supportive Care:
Continuous cardiorespiratory monitoring
Respiratory support as needed (e.g., nasal cannula, CPAP, mechanical ventilation)
Pain control with judicious use of opioids and non-opioid analgesics
Early mobilization once stable
Nutritional support
Prevention of infection.
Complications
Early Complications:
Pain at the insertion site
Bleeding
Injury to surrounding structures (lung parenchyma, intercostal vessels/nerve)
Malposition of the tube
Subcutaneous emphysema
Re-expansion pulmonary edema.
Late Complications:
Persistent air leak
Empyema
Persistent pneumothorax
Tube blockage or dislodgement
Formation of bronchopleural fistula
Chronic pain.
Prevention Strategies:
Strict adherence to sterile technique during insertion
Careful selection of insertion site and tube size
Use of imaging to confirm placement
Proper management of the drainage system
Adequate pain control to facilitate deep breathing and coughing
Prompt identification and management of air leaks.
Prognosis
Factors Affecting Prognosis:
Underlying cause of pneumothorax
Size and duration of pneumothorax
Presence of underlying lung disease
Promptness and adequacy of treatment
Development of complications.
Outcomes:
Most pediatric patients with pneumothorax treated with chest tube management have a good prognosis with complete lung re-expansion and resolution of symptoms
However, recurrent pneumothorax can occur, especially in patients with underlying lung disease
Outcomes are generally favorable with appropriate care.
Follow Up:
Follow-up chest X-rays may be required to ensure complete lung re-expansion and monitor for recurrence
For patients with underlying lung disease, regular outpatient follow-up with a pulmonologist is recommended
Education on recognizing symptoms of recurrence is important.
Key Points
Exam Focus:
Indications for chest tube insertion in pediatric pneumothorax (symptomatic, large, tension, ventilated patients)
Correct intercostal space and location for insertion (e.g., 4th/5th IC space, mid-axillary line)
Understanding the mechanics of a water-seal drainage system
Recognizing complications like tension pneumothorax and re-expansion pulmonary edema.
Clinical Pearls:
Use blunt dissection to avoid injuring intercostal vessels and nerves
Always confirm tube placement with a post-procedure CXR
Monitor the drainage system closely for air leaks and output
Pain management is critical for patient comfort and pulmonary toilet
Consider ultrasound for rapid bedside diagnosis of pneumothorax in unstable patients.
Common Mistakes:
Incorrect tube size for patient age/size
Failure to achieve complete lung re-expansion
Neglecting pain management leading to poor ventilation
Inadequate monitoring of drainage system
Clamping the tube for prolonged periods without indication
Misinterpreting air leak on the water-seal device.