Last week I wrote about pneumomediastinum in children (click here to read). This week I’ll talk about a somewhat more common problem: pneumothorax. This condition is far more mysterious than in adults.
Sports related pneumothorax rarely occurs without rib fractures, which are themselves uncommon in children. The usual mechanism is barotrauma, most likely from an impact while the glottis is closed. The typical presentation is that of pleuritic chest pain, which may be followed by dyspnea. Focal chest wall tenderness is typically absent. Teenagers tend to engage in more strenuous activity and are more likely to actually sustain a rib fracture, so they may have focal tenderness over the fracture site.
Spontaneous pneumothorax in children is also uncommon. However, it is a very different entity. It may be related to blebs in the lungs, and may be more common in children who were born prematurely. The recurrence rate after successful treatment is approximately 50% (in small series). Recurrence is not predictable by looking for blebs on chest CT. The recurrence rate is significantly lower after VATS.
Bottom line: A child who complains of pleuritic chest pain, and especially dyspnea, should undergo a simple PA chest xray. If a pneumothorax is present, consider the following:
- Insert a small chest tube or catheter if needed, the smaller the better. (I’m stilling looking for the answer to the question of how big a pneumothorax is big enough)
- Don’t use high inspired oxygen; it doesn’t work. (Read my older blogs from 2010 – this one and this one, too)
- Don’t get a chest CT for either the initial pneumothorax or any recurrences (too much radiation, too little utility)
- If this is a spontaneous pneumothorax, caution the parents on the possibility of recurrence
- If a spontaneous pneumothorax does recur, consult a pediatric surgeon to consider VATS pleurodesis
- When can the child return to sports? There is absolutely no good literature. I recommend the usual time it takes most soft tissues to return to full tensile strength after injury (6 weeks).
- Management of primary spontaneous pneumothorax in children. Clin Pediatr, online ahead of print, April 11, 2011.
- Sports-related pneumothorax in children. Pediatric Emergency Care 21(4): 259-260, 2005.
Thanks to Chris Chow MD for finding some of the literature for this post.