Patient Presentation
A 4 month old male came to the emergency room with fever to 103° and cough for 48 hours. The coughing had been much worse over the past day but there was no apnea or cyanosis. The patient had not had anything to drink for the past 8 hours. The past medical history showed a full-term infant without neonatal problems. He was current on immunizations. The family history showed no pulmonary disease.
The pertinent physical exam revealed a tired appearing male with a respiratory rate of 62, pulse of 114, with normal blood pressure and temperature. His pulse oximeter was 88% on room air. His capillary refill was 3 seconds. HEENT showed clear rhinitis. Lungs had some mild coarse breath sounds throughout the fields with decreased sounds on the right. The rest of his examination was normal. The work-up included a venous blood gas of pH= 7.34, CO2 = 38 and O2 of 56 with a base of -6. A respiratory viral panel was negative for influenza, respiratory syncytial virus and other viruses. A pertussis nasal swab was also negative. The radiologic evaluation of a chest radiograph showed a right upper lobe consolidation with a moderate apical/anterior pneumothorax and small pneumomediastinum. The diagnosis of bilateral lower lobe pneumonia and spontaneous pneumothorax and pneumomediastum was made. He was treated conservatively with oxygen at 100% by nasal canula, IV fluids and antibiotics for community-acquired pneumonia. He was slowly improving clinically after 5 days.
Figure 105 – 06-20-13 – AP view of the chest demonstrates right upper lobe collapse, patchy bibasilar infiltrates felt to represent bacterial pneumonia, and pneumomediastium outlining the inferior border of the heart – a continuous diaphragm sign.
Figure 106 – 06-20-13 – Left lateral decubitus view of the chest demonstrates a small right pneumothorax.
Discussion
“A pneumothorax is a collection of air in the pleural space, and it can be categorized into spontaneous, traumatic or iatrogenic. Spontaneous pneumothorax can be further classified into primary with no clinical evidence of underlying lung disease or secondary due to pre-existing lung disease.”
Spontaneous pneumothorax is a condition that is relatively rare in pediatrics. There is a bimodal age distribution – neonates and late adolescence. It is caused by tearing of the visceral pleural. Clinical signs include chest pain, dyspnea, tachycardia, tracheal deviation towards contralateral side, hypotension, cyanosis.
There is a wide variation in treatment practices particularly for large pneumothoraces. For small ones, most are treated conservatively with or without oxygen therapy, and treatment for an underlying cause if present. Large pneumothoraces can be treated conservatively, by aspiration, chest tube, pleurodesis and/or surgery. The pneumothorax is seen on AP radiographs, but decubutus radiographs often make the pneumothorax more prominent. Because air will track anteriorly on a supine chest radiograph often used in small children, pneumothorax in these children can easily be missed on the AP but not on the decubitus radiograph.
To review the complications of pneumonia and its common infectious disease causative agents, see What Are the Complications of Pneumonia?.
Learning Point
Causes of secondary spontaneous pneumothorax include:
- Airway disease
- Asthma, associated with
- Bronchopulmonary dysplasia
- Bronchiectesis
- Cystic fibrosis
- Congenital lung disease
- Congenital lobar emphysema
- Cystic adenomatoid malformation
- Interstitial lung disease
- Saroidosis
- Langerhans cell histiocytosis
- Infectious disease
- Measles
- Pneumonia or abscess
- Pneumocystis jirovecii
- Parasitic, especially ecchinococcal
- Tuberculosis
- Connective tissue disease
- Marfan
- Dermatomyositis
- Ehler-Dahlos
- Polymyositis
- Systemic lupus erythematosis
- Other
- Catamenial pneumothorax or intrathoracic endometriosis
- Foreign body
- Malnutrition
Questions for Further Discussion
1. What is the pathophysiology behind treating with oxygen for pneumothorax?
2. How should a recurrent pneumothorax be treated?
Related Cases
- Disease: Spontaneous Pneumothorax | Pleural Disorders | Lung Disease
- Symptom/Presentation: Fever and Fever of Unknown Origin | Respiratory Distress
- Specialty: Allergy / Pulmonary Diseases | Radiology / Nuclear Medicine / Radiation Oncology | Surgery
- Age: Infant
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Pleural Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Michel JL. Spontaneous pneumothorax in children. Arch Pediatr. 2000 Mar;7 Suppl 1:39S-43S.
O’Lone E, Elphick HE, Robinson PJ. Spontaneous pneumothorax in children: when is invasive treatment indicated? Pediatr Pulmonol. 2008 Jan;43(1):41-6.
Robinson PD, Cooper P, Ranganathan SC. Evidence-based management of paediatric primary spontaneous pneumothorax. Paediatr Respir Rev. 2009 Sep;10(3):110-7.
Roberts D, Wacogne I. Question 3. In patients with spontaneous pneumothorax, does treatment with oxygen increase resolution rate? Arch Dis Child. 2010 May;95(5):397-8.
Kurihara M, Kataoka H, Ishikawa A, Endo R. Latest treatments for spontaneous pneumothorax. Gen Thorac Cardiovasc Surg. 2010 Mar;58(3):113-9.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
16. Learning of students and other health care professionals is facilitated.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 