Pediatric emergency medicine trisk 4085 4085
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return, as well as from shifting mediastinal structures (particularly in younger
children) with compression of the cardiovascular structures.
Clinical Assessment. The symptoms and signs of pneumothorax depend on the
size of the pleural collection and how rapidly it occurs. The most common
presenting symptoms are unilateral chest pain and dyspnea. For example, it is
common for a patient with spontaneous rupture of an emphysematous bleb to
complain of sudden acute pain on the involved side of the chest followed by
tachypnea, pain at the tip of the ipsilateral shoulder, and a sense of shortness of
breath. Such patients usually have a small to moderate pneumothorax (less than
20% of the lung volume), often with no accompanying hypoxia. Decreased breath
sounds may be heard on the ipsilateral side, and a chest radiograph will usually
demonstrate the pneumothorax, particularly if taken at end expiration. Patients
with a more longstanding pneumothorax may not even be in pain.
In general, a patient with a pneumothorax of 50% or more of the lung volume
will exhibit signs and symptoms of ventilatory impairment: dyspnea, tachypnea,
pain, splinting on the involved side, agitation, increased pulse rate, diminished
breath sounds, and increased resonance to percussion on the involved side.
Displacement of the trachea and heart away from the involved side occurs in large
pneumothoraces. Severe dyspnea should alert the physician to the possibility of a
very large or possible tension pneumothorax. A child with existing underlying
lung disease may display more severe symptoms and hypoxemia with a small or
moderate pneumothorax.
In addition to describing symptoms, the patient with pneumothorax should be
asked about potential predisposing conditions or risk factors including asthma,
foreign-body aspiration, underlying infections, inhaled drug use, activities at
onset of symptoms, and history of any prior pneumothoraces.
If the patient’s condition is not severe, an immediate upright PA and a lateral
chest radiograph should be taken. These radiographs are important to determine
not only the site and extent of the pneumothorax but also any complicating
features such as tumor, fluid within the pleural space, or abnormalities of the
lungs, diaphragm, or mediastinum.
Management. There are currently no widely accepted pediatric guidelines
regarding management of spontaneous pneumothoraces. Approaches may vary
depending on the extent of the pneumothorax, the severity of symptoms, ongoing
expansion, presence of tension physiology, and the suspected underlying etiology
or clinical condition. Small spontaneous pneumothoraces (e.g., less than 15% to
20% of lung volume) that are asymptomatic can typically be managed with
