title: Management of large primary spontaneous pneumothorax in children: radiological guidance, surgical intervention and proposed guideline.
abstract: OBJECTIVE
  Primary spontaneous pneumothorax (PSP) is managed in accordance with the adult British Thoracic Society (BTS) guidelines due to lack of paediatric evidence and consensus. We aim to highlight the differences and provide a best practice surgical management strategy for PSP based on experience of two major paediatric surgical centres.
  
  
  METHODS
  Retrospective review of PSP management and outcomes from two UK Tertiary Paediatric hospitals between 2004 and 2015.
  
  
  RESULTS
  Fifty children with 55 PSP (5 bilateral) were referred to our Thoracic Surgical Services after initial management: 53% of the needle aspirations failed. Nine children (20%) were associated with visible bullae on the initial chest X-ray. Forty-nine children were assessed with computed tomography scan (CT). Apical emphysematous-like changes (ELC) were identified in 37 children (75%). Ten children had also bullae in the asymptomatic contralateral lungs (20%). In two children (4%), CT demonstrated other lung lesions: a tumour of the left main bronchus in one child; a multi-cystic lesion of the right middle lobe in keeping with a congenital lung malformation in another child. Contralateral asymptomatic ELC were detected in 20% of the children: of those 40% developed pneumothorax within 6 months. Best surgical management was thoracoscopic staple bullectomy and pleurectomy with 11% risk of recurrence. Histology confirmed ELC in 100% of the apical lung wedge resections even in those apexes apparently normal at the time of thoracoscopy.
  
  
  CONCLUSIONS
  Our experience suggests that adult BTS guidelines are not applicable to children with large PSP. Needle aspiration is ineffective. We advocate early referral to a Paediatric Thoracic Service. We suggest early chest CT scan to identify ELC, for counselling regarding contralateral asymptomatic ELC and to rule out secondary pathological conditions causing pneumothorax. In rare instance if bulla is visible on presenting chest X-ray, thoracoscopy could be offered as primary option.
authors: Department of Paediatric Surgery, Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK. giampsoccorso@doctors.org.uk.
authors: Giampiero
authors: G
authors: Soccorso
authors: Department of Paediatric Surgery, Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK.
authors: Ravindar
authors: R
authors: Anbarasan
authors: Department of Paediatric Surgery, Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK.
authors: Michael
authors: M
authors: Singh
authors: Paediatric Surgical Unit, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK.
authors: Richard M
authors: RM
authors: Lindley
authors: Paediatric Surgical Unit, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK.
authors: Sean S
authors: SS
authors: Marven
authors: Department of Paediatric Surgery, Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK.
authors: Dakshesh H
authors: DH
authors: Parikh
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D008297:Male; D011030:Pneumothorax / Q000000981:diagnostic imaging* / Q000601:surgery*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D020775:Thoracic Surgery, Video-Assisted; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: Bullectomy; Children; Pleurectomy; Primary spontaneous pneumothorax; Thoracoscopic surgery