Management of Spontaneous Pneumothorax in Children: A Systematic Review and Meta-Analysis

Abstract

Introduction Management of primary spontaneous pneumothorax (PSP) is mainly based on adults. Data are controversial with regards to its management in children. We aimed to assess: (1) the length of hospital stay (LOS) between conservative management (i.e., observation with O₂ administration), aspiration/chest drain, and surgical management; (2) the risk of recurrence after nonsurgical treatment versus surgery; (3) the risk of recurrence in the presence of bullae.

Materials and Methods Using a defined search strategy, three independent investigators identified all the studies on the management of PSP in children. Case reports, opinion articles, and gray literature publications were excluded. The study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A meta-analysis was performed using RevMan 5.3. Data are expressed as mean ± SD.

Results Of 3,089 abstracts screened, 95 full-text were analyzed, 23 were included in the quantitative analysis, and 16 were included in the meta-analysis (1,633 patients). LOS was similar between conservative and surgical management (6.2 ± 0.8 days vs. 5.9 ± 1.4 days; p = ns). Recurrence of PSP was significantly higher among children with a nonsurgical management (32%) versus those surgically treated (18%; p = 0.002). The incidence of recurrence was slightly higher in patients managed by aspiration/chest drain (34%) compared with those with a conservative management (27%; p = 0.05). Risk of recurrence in patients with or without documented bullae was not significantly different (26 vs. 38%, respectively; p = ns).

Conclusion Given the lack of a standardized management of pediatric PSP, the present study seems to demonstrate a better outcome in children treated with surgery as first-line of management.

Level of Evidence This is a Level III study.

Keywords

spontaneous pneumothorax - children - systematic review - meta-analysis

• References

• 1 Brown SG, Ball EL, Perrin K. , et al. Study protocol for a randomised controlled trial of invasive versus conservative management of primary spontaneous pneumothorax. BMJ Open 2016; 6 (09) e011826
• 2 Zganjer M, Cizmić A, Pajić A, Cigit I, Zganjer V. Primary spontaneous pneumothorax in pediatric patients: our 7-year experience. J Laparoendosc Adv Surg Tech A 2010; 20 (02) 195-198
• 3 Lee LP, Lai MH, Chiu WK, Leung MW, Liu KK, Chan HB. Management of primary spontaneous pneumothorax in Chinese children. Hong Kong Med J 2010; 16 (02) 94-100
• 4 Dotson K, Timm N, Gittelman M. Is spontaneous pneumothorax really a pediatric problem? A national perspective. Pediatr Emerg Care 2012; 28 (04) 340-344
• 5 Matuszczak E, Dębek W, Hermanowicz A, Tylicka M. Spontaneous pneumothorax in children—management, results, and review of the literature. Kardiochir Torakochirurgia Pol 2015; 12 (04) 322-327
• 6 Nathan N, Guilbert J, Larroquet M, Lenoir M, Clement A, Epaud R. Efficacy of blebs detection for preventive surgery in children's idiopathic spontaneous pneumothorax. World J Surg 2010; 34 (01) 185-189
• 7 Seguier-Lipszyc E, Elizur A, Klin B, Vaiman M, Lotan G. Management of primary spontaneous pneumothorax in children. Clin Pediatr (Phila) 2011; 50 (09) 797-802
• 8 Robinson PD, Cooper P, Ranganathan SC. Evidence-based management of paediatric primary spontaneous pneumothorax. Paediatr Respir Rev 2009; 10 (03) 110-117
• 9 MacDuff A, Arnold A, Harvey J. ; BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 (Suppl. 02) ii18-ii31
• 10 Cook CH, Melvin WS, Groner JI, Allen E, King DR. A cost-effective thoracoscopic treatment strategy for pediatric spontaneous pneumothorax. Surg Endosc 1999; 13 (12) 1208-1210
• 11 Soler LM, Raymond SL, Larson SD, Taylor JA, Islam S. Initial primary spontaneous pneumothorax in children and adolescents: operate or wait?. J Pediatr Surg 2018; 53 (10) 1960-1963
• 12 Lopez ME, Fallon SC, Lee TC, Rodriguez JR, Brandt ML, Mazziotti MV. Management of the pediatric spontaneous pneumothorax: is primary surgery the treatment of choice?. Am J Surg 2014; 208 (04) 571-576
• 13 Chung PH, Wong KK, Lan LC, Tam PK. Thoracoscopic bullectomy for primary spontaneous pneumothorax in pediatric patients. Pediatr Surg Int 2009; 25 (09) 763-766
• 14 Poenaru D, Yazbeck S, Murphy S. Primary spontaneous pneumothorax in children. J Pediatr Surg 1994; 29 (09) 1183-1185
• 15 Young Choi S, Beom Park C, Wha Song S. , et al. What factors predict recurrence after an initial episode of primary spontaneous pneumothorax in children?. Ann Thorac Cardiovasc Surg 2014; 20 (06) 961-967
• 16 Beg MH, , Reyazuddin, Faridi MM, Ahmad SH, Shahab T. Spontaneous pneumothorax in children—a review of 95 cases. Ann Trop Paediatr 1988; 8 (01) 18-21
• 17 Wilcox DT, Glick PL, Karamanoukian HL, Allen JE, Azizkhan RG. Spontaneous pneumothorax: a single-institution, 12-year experience in patients under 16 years of age. J Pediatr Surg 1995; 30 (10) 1452-1454
• 18 Baumann MH, Strange C, Heffner JE. , et al; AACP Pneumothorax Consensus Group. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001; 119 (02) 590-602
• 19 Qureshi FG, Sandulache VC, Richardson W, Ergun O, Ford HR, Hackam DJ. Primary vs delayed surgery for spontaneous pneumothorax in children: which is better?. J Pediatr Surg 2005; 40 (01) 166-169
• 20 PROSPERO international prospective register of systematic reviews. Available at: https://www.crd.york.ac.uk/prospero . Accessed May 15, 2019
• 21 Moher D, Liberati A, Tetzlaff J, Altman DG. ; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 2009; 62 (10) 1006-1012
• 22 Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 2005; 5: 13 . doi:10.1186/1471-2288-5-13
• 23 Review Manager 5 (RevMan). The Cochrane Collaboration. Copenhagen: The Nordic Cochrane Centre; 2014
• 24 Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 2003; 73 (09) 712-716
• 25 Guyatt GH, Oxman AD, Vist GE. , et al; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336 (7650): 924-926
• 26 Dupont WD, Plummer Jr WD. Power and sample size calculations. A review and computer program. Control Clin Trials 1990; 11 (02) 116-128
• 27 Williams K, Lautz TB, Leon AH, Oyetunji TA. Optimal timing of video-assisted thoracoscopic surgery for primary spontaneous pneumothorax in children. J Pediatr Surg 2018; 53 (09) 1858-1861
• 28 Williams K, Oyetunji TA, Hsuing G, Hendrickson RJ, Lautz TB. Spontaneous pneumothorax in children: national management strategies and outcomes. J Laparoendosc Adv Surg Tech A 2018; 28 (02) 218-222
• 29 Soccorso G, Anbarasan R, Singh M, Lindley RM, Marven SS, Parikh DH. Management of large primary spontaneous pneumothorax in children: radiological guidance, surgical intervention and proposed guideline. Pediatr Surg Int 2015; 31 (12) 1139-1144
• 30 Noh D, Lee S, Haam SJ, Paik HC, Lee DY. Recurrence of primary spontaneous pneumothorax in young adults and children. Interact Cardiovasc Thorac Surg 2015; 21 (02) 195-199
• 31 Smith J, Schumacher RE, Donn SM, Sarkar S. Clinical course of symptomatic spontaneous pneumothorax in term and late preterm newborns: report from a large cohort. Am J Perinatol 2011; 28 (02) 163-168
• 32 Chambers A, Scarci M. In patients with first-episode primary spontaneous pneumothorax is video-assisted thoracoscopic surgery superior to tube thoracostomy alone in terms of time to resolution of pneumothorax and incidence of recurrence?. Interact Cardiovasc Thorac Surg 2009; 9 (06) 1003-1008
• 33 Davis AM, Wensley DF, Phelan PD. Spontaneous pneumothorax in paediatric patients. Respir Med 1993; 87 (07) 531-534
• 34 Yu VY, Liew SW, Robertson NR. Pneumothorax in the newborn. Changing pattern. Arch Dis Child 1975; 50 (06) 449-453
• 35 Williams K, Baumann L, Grabowski J, Lautz TB. Current practice in the management of spontaneous pneumothorax in children. J Laparoendosc Adv Surg Tech A 2019; 29 (04) 551-556
• 36 Shea BJ, Grimshaw JM, Wells GA. , et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007; 7: 10