What is Pneumothorax in Children? Who is more common?

Pneumothorax is the deflation of the lung when air escapes into the chest cavity, between the lung membranes. The lung deflates and shrinks and not enough air can enter the lungs and shortness of breath occurs, the blood cannot carry oxygen to the tissues.

Primary spontaneous pneumothorax is about 4 times more common in men and about 3 times more common on the left side. It is usually seen in people with a thin, thin and tall build, which we call asthenic type.

Are There Types of Pneumothorax in Children?

Yes, there are. Pneumothorax can develop in children without a known cause (primary) or due to causes such as trauma, asthma, bronchiectasis (secondary). Classification can be made as follows in general.

A- Spontaneous Pneumothorax

• Primary Spontaneous Pneumothorax (Causes; Apical bullae, Familial, Smoking)
• Secondary Spontaneous Pneumothorax (Causes; There is always an underlying disease, Infections (Pneumonia, tbc, ...), Neoplasms (Metastases, sarcomas, Hodgin lymphoma), Congenital cystic adenomatoid malformation, Alpha 1 antitrypsin deficiency
• Neonatal Pneumothorax: The cause is unknown.

B- Acquired Pneumothorax

1. Iatrogenic causes
   1. Transthoracic biopsy
   2. Subclavian catheterization
   3. Thoracentesis, chest tube insertion
2. Barotrauma
   1. Mechanical ventilation
   2. Ambulation
3. Traumatic
   1. Penetrating trauma
   2. Firearm injury
   3. Blunt traumas
   4. As a result of surgical intervention

We can also divide it into Simple and Complex Pneumothoraces.

How Does Spontaneous Pneumothorax Present?

Patients are usually children with no lung problems and present to the emergency outpatient clinic with complaints of sudden onset of shortness of breath, chest pain, sweating, drop in blood pressure, tachycardia and cough with or without exertion such as after gym class. The present complaints are usually not severe enough to cause severe respiratory distress.

Neonatal Primary Spontaneous Pneumothoraces are usually seen in term and normal birth weight babies. Sudden onset of respiratory distress, nasal wing breathing and inter costal retractions, cyanosis and tachycardia develop in infants.

How is Pneumothorax Diagnosed in Children?

The diagnosis is made by history and physical examination and confirmed by imaging and laboratory studies. The diagnosis is made by history (described above) and partly by physical examination findings (nasal wing breathing, tachycardia, intercostal retraction, low blood pressure and decreased or absent respiratory sounds on the side of the pneumothorax when listened with a stethoscope, heart sounds are displaced across).

The diagnosis is made when the lung on that side deflates and there is air in the chest cavity on the chest X-ray. Rarely, computed tomography may be required, especially to determine the underlying cause.

Is it necessary to perform computed tomography in every patient with pneumothorax?

No, it is not necessary. If a disease causing pneumothorax is suspected, or if there is a recurrent pneumothorax, a CT scan should be performed.

Left pneumothorax on chest X-ray

How is pneumothorax treated in children?

The degree of pneumothorax, the presence or absence of an underlying disease and the patient's clinic are decisive in the treatment. If the patient's clinic is mild, the pneumothorax is simple and there is no underlying cause, the patient can be followed up and may recover spontaneously.

Which Patients Should Surgery Be Performed?

Surgical intervention should be considered in patients with severe pneumothorax and if the patient has a clinic, recurrent pneumothorax, pneumothorax that occurs for the first time in patients living far from the health institution, and pneumothorax on both sides of the chest cavity.

What are the Surgical Methods in Pneumothorax?

1-Installation of a chest tube (drain)

Under sedation anesthesia, a silicone drain about the width of a pencil is inserted into the chest cavity between the 5th and 6th ribs on the affected side. This drain is connected to a sterile unit consisting of a bottle with water at the bottom. When the air in the chest cavity is emptied, the deflated lung is restored. In patients with pneumothorax that persists for more than 2 weeks with this treatment, some drugs can be administered through the thoracic drain to create pleurodesis.

2-Open surgery

A 3-4 cm long incision is made in the thoracic wall (chest wall) and the 3rd or 5th ribs are opened with the help of a retractor. The air sacs in the lung are removed with a special method. The upper part of the pleura, the outer membrane of the lung, can be removed (pleurectomy) or a reaction can be created here and the lung adhered (pleurodesis). This procedure is usually performed for recurrent pneumothoraxes or pneumothoraxes that do not improve with thoracic drain treatment. It is applied in cases that do not improve in 5-7 days despite the insertion of a drain or in patients with recurrent pneumothorax.

Thus, collapse of the lung and air accumulation in the chest cavity are prevented. At the end of the operation, a drain is placed into the chest cavity and the folds are closed in the anatomical plan. The drain is removed 1 or 2 days after surgery.

Treatment with 3-VATS method.

What is VATS? Is pneumothorax treatment performed with this method?

VATS means video assisted thoracoscopic surgery. In other words, it is the closed operation of the thorax (chest cavity). Pneumothorax can also be treated with this method. Especially pneumothoraces caused by apical bullae and seen in young people are easily treated with this method.

How is VATS performed?

In closed surgery methods, a large incision between the ribs is not made as in open surgery. It does not have to be opened by placing a retractor. Instruments with a diameter of 5 - 10 mm are inserted into the thoracic wall (chest wall) through 2 or 3 holes and surgeries are performed through these holes. Closed surgeries provide a wider viewing angle than open surgeries.

Are there any advantages of closed surgery (thoracoscopy)?

Yes, there are, the main ones are; it has many advantages such as less pain, shorter recovery time and being more aesthetic. The thorocoscopic method provides a wider angle of view than open surgery. The patient may need to stay in intensive care for one day and is discharged in 2-3 days.

It should not be forgotten that thoroscopic (closed) surgeries require serious experience, knowledge and skill along with advanced technology. Otherwise, serious complications may occur.

What are the other diseases for which VATS is used in children?

• Pneumothorax
• Biopsy and removal of chest cavity tumors; Neuroblastoma, Lymphoma
• Congenital Diseases of the Lung; Cysts, CHAM, Lung Sequestration etc.
• Thymus Pathologies
• Esophageal atresia
• Diaphragmatic Hernia and Relaxation
• Pleural Empyema
• Lung Cysts in Infants and Adults
• Chest Wall Deformities (pectus eskavatum)

What are the risks of surgery?

Risks such as air leakage from the lung, bleeding, infection and recurrence of the disease, heart and large vessel injury may occur. The surgeon minimizes the risks by taking the necessary precautions according to these situations. The incidence of these complications after closed surgery for pneumothorax is between 2-10%. This rate is much higher in open surgeries.

How many days hospitalization is required after surgery?

Although there is no general standard duration, on average; hospitalization is required for 5-7 days only in case of drain placement, 7-14 days after open surgeries and 3-5 days after closed - endoscopic surgeries.

What are the Recurrence Rates of Pneumothorax?

• In people who have had a pneumothorax once, there is a 20% chance of the disease recurring after a while if it is treated only by placing a chest tube (drain).
• In people who have had two pneumothoraxes and have been treated only by placing a drain, there is a 50% chance of it happening for the third time.
• In people who have had surgery, the chance of recurrence of pneumothorax is between 3-5%.

In a person who has had a pneumothorax once, thorax computed tomography should be performed to investigate whether there are bubbles causing this disease. If bubbles are detected, VATS operation will prevent recurrences.

*** The information provided here and the content of the website are designed to inform the visitor, especially the families. No information should be considered as advice by visitors and should not lead to any decision or action. Families should definitely have their patient examined by a pediatric surgeon, consult with him/her and make a decision by consulting his/her knowledge.