Presenter Status
Fellow
Abstract Type
Research
Primary Mentor
Shawn D St Peter MD FACS
Start Date
10-5-2023 12:30 PM
End Date
10-5-2023 12:45 PM
Presentation Type
Abstract
Description
Background: Primary spontaneous pneumothorax (PSP) affects 3.4 per 100,000 children in the United States. Regardless of the initial management, additional procedures, and prolonged hospital length of stay (LOS) may occur. There is currently no consensus in the pediatric surgical community on the optimal management of these patients, which has resulted in marked variability in management. The Midwest Pediatric Surgery Consortium (MWPSC), of which our site is a participant, suggested a management algorithm to include simple aspiration upon presentation, and if this fails, VATS should be considered.
Objectives/Goal: The purpose of this study was to evaluate the outcomes of instituting a simple aspiration protocol for the initial management of PSP in the pediatric population. We hypothesized that there would be a significant reduction in LOS, disease recurrence and morbidity.
Methods/Design: Single institution analysis of prospectively collected data was conducted on all patients between 12 and 18 years who were diagnosed with PSP from January 2016 to January 2021. Patients with pneumothorax secondary to trauma or underlying pulmonary disease, bilateral pneumothorax, hemodynamic instability with tension physiology, small pneumothorax stable under observation (2 cm or less), patients with a previously treated ipsilateral pneumothorax and those referred after initial intervention at another facility were excluded. Initial management consisted of aspiration alone with a 12F percutaneous thoracostomy tube followed by clamping of the tube and antero-posterior chest radiograph (CXR) at 6 hours. Success was defined as the presence of residual small pneumothorax (less than 2cm distance between the chest wall and lung at the apex) and no air leak when the clamp was released. These patients were discharged. If aspiration failed, VATS was performed next available with the surgeon on call. Patients with a small pneumothorax were observed as an inpatient prior to a decision for intervention.
Results: Fifty-nine patients were included in the analysis. The median age was 16.8 years (IQR 15.9, 17.3). Aspiration was successful in 33% (n=20) patients, and they were subsequently discharged home. VATS was performed in all patients who failed simple aspiration (66%, n=39). The median time from failure of aspiration to VATS was 9.6 hours (IQR 6.1, 13.2). The median LOS for those with successful aspiration was 20.4 hours (IQR 16.8, 34.8), while those who underwent VATS after failing aspiration had a median LOS of 3.1 days (IQR 2.6, 4). Of those who had successful aspiration, 45% (n=9) had recurrent PSP. Of the 39 patients who initially underwent VATS after a failed aspiration, 25% (n=10) had recurrent PSP. The median time to recurrence for the successful aspiration group was shorter than that of the VATS group [16.6 days (IQR 5.4, 19.2) vs. 389.5 days (IQR 94.1, 907.0).
Conclusions: Simple aspiration of PSP as initial management for children with their first presentation reliably predicts the need for operative intervention. The decision to operate may be made within six hours, allowing for early VATS. Though recurrence rates are high whether aspiration is successful or not, incorporating this management protocol likely minimizes morbidity, hospital length of stay and cost.
MeSH Keywords
Spontaneous pneumothorax; thoracoscopic surgery; pediatric
Additional Files
1341-Shai Stewart-presentation-Abstract.pdf (214 kB)Abstract
PSP Results Flow Diagram.png (25 kB)
Results flow diagram
Included in
Higher Education and Teaching Commons, Medical Education Commons, Pediatrics Commons, Science and Mathematics Education Commons, Surgery Commons
Management of Primary Spontaneous Pneumothorax in Children: A Single Institution Protocol Analysis
Background: Primary spontaneous pneumothorax (PSP) affects 3.4 per 100,000 children in the United States. Regardless of the initial management, additional procedures, and prolonged hospital length of stay (LOS) may occur. There is currently no consensus in the pediatric surgical community on the optimal management of these patients, which has resulted in marked variability in management. The Midwest Pediatric Surgery Consortium (MWPSC), of which our site is a participant, suggested a management algorithm to include simple aspiration upon presentation, and if this fails, VATS should be considered.
Objectives/Goal: The purpose of this study was to evaluate the outcomes of instituting a simple aspiration protocol for the initial management of PSP in the pediatric population. We hypothesized that there would be a significant reduction in LOS, disease recurrence and morbidity.
Methods/Design: Single institution analysis of prospectively collected data was conducted on all patients between 12 and 18 years who were diagnosed with PSP from January 2016 to January 2021. Patients with pneumothorax secondary to trauma or underlying pulmonary disease, bilateral pneumothorax, hemodynamic instability with tension physiology, small pneumothorax stable under observation (2 cm or less), patients with a previously treated ipsilateral pneumothorax and those referred after initial intervention at another facility were excluded. Initial management consisted of aspiration alone with a 12F percutaneous thoracostomy tube followed by clamping of the tube and antero-posterior chest radiograph (CXR) at 6 hours. Success was defined as the presence of residual small pneumothorax (less than 2cm distance between the chest wall and lung at the apex) and no air leak when the clamp was released. These patients were discharged. If aspiration failed, VATS was performed next available with the surgeon on call. Patients with a small pneumothorax were observed as an inpatient prior to a decision for intervention.
Results: Fifty-nine patients were included in the analysis. The median age was 16.8 years (IQR 15.9, 17.3). Aspiration was successful in 33% (n=20) patients, and they were subsequently discharged home. VATS was performed in all patients who failed simple aspiration (66%, n=39). The median time from failure of aspiration to VATS was 9.6 hours (IQR 6.1, 13.2). The median LOS for those with successful aspiration was 20.4 hours (IQR 16.8, 34.8), while those who underwent VATS after failing aspiration had a median LOS of 3.1 days (IQR 2.6, 4). Of those who had successful aspiration, 45% (n=9) had recurrent PSP. Of the 39 patients who initially underwent VATS after a failed aspiration, 25% (n=10) had recurrent PSP. The median time to recurrence for the successful aspiration group was shorter than that of the VATS group [16.6 days (IQR 5.4, 19.2) vs. 389.5 days (IQR 94.1, 907.0).
Conclusions: Simple aspiration of PSP as initial management for children with their first presentation reliably predicts the need for operative intervention. The decision to operate may be made within six hours, allowing for early VATS. Though recurrence rates are high whether aspiration is successful or not, incorporating this management protocol likely minimizes morbidity, hospital length of stay and cost.
