A 17-year-old boy presents with sudden onset of right pleuritic chest pain. His HR is 70 bpm and his oyxgen saturation is 98% on room air. He is comfortable, speaking in full sentences, and has decreased breath sounds on the right. His CXR is shown.

 

 

[size=20px]While observed in the ER, the patient’s condition remains the same 4 hours later. What is the most appropriate management?

 

A Repeat CXR

 

B Obtain chest CT scan

 

C Rigid bronchoscopy

 

D Place pigtail chest tube and place to suction

 

E Insert pigtail chest tube and place to water seal[/size]

B

A) Repeat CXR before sending home

A

B obtain CT chesr scan

A repeat chest X ray before sending home

Why have you not considered the option of aspiration of his symptomatic spontaneous pneumothorax?

B

Correct answer

A Repeat CXR

 

Primary spontaneous pneumothorax often presents with acute pleuritic chest pain. The diagnosis is confirmed with chest x-ray as in this case. Symptomatic spontaneous pneumothorax has been traditionally treated with chest tube placement to re-expand the lung. However, recent studies have suggested that a more conservative approach may be warranted. A recent randomized controlled trial of pediatric and adult patients (age 14-50 years) compared conservative management to immediate interventional management for moderate-large, unilateral spontaneous pneumothorax. Patients in the conservative group were observed for a minimum of 4 hours after which a repeat CXR was obtained. Patients were discharged if the CXR was stable and patients did not require oxygen and were able to ambulate. Reexpansion of the lung at 8 weeks occurred in 118 of 125 (94.4%) patients with conservative management compared to 129 of 131 (98.5%) with interventional management. The median time to radiologic resolution was shorter in the interventional group (16 days vs. 30 days). Complete resolution of symptoms by 8 weeks was seen in 139 of 147 (94.6%) patients with conservative management compared to 128 of 137 (93.4%) with interventional management. Recurrence was more frequent in the intervention group (16.8% vs. 8.8%). Adverse events were also higher in the intervention group (RR 3.32; 95% CI 1.85-5.95). If repeat CXR is unchanged, this patient meets all of the criteria for conservative management and discharge from the ER.

 

Another option to treat primary spontaneous pneumothorax is with simple aspiration. Aspiration can be performed through a pigtail catheter followed by clamping the catheter. After 6 hours of observation, a repeat chest x-ray is obtained. If the repeat CXR shows small or no pneumothorax, then the patient may be discharged home. The rate of recurrence was lower in patients who passed this aspiration test compared to those who failed.

 

These studies and treatment options are summarized in the following visual abstract located on PedSurgLibrary.com courtesy of the APSA Education Committee.