Spontaneous Pneumothorax

Introduction

Welcome to the APSA Quality and Safety Committee Spontaneous Pneumothorax Toolkit. This page is intended to help anyone who is interested in quality improvement of the management of patients with spontaneous pneumothorax.

Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.

Projects

Various institutions have implemented protocols for the management of spontaneous pneumothorax, given the lack of consensus and standardized practices, leading to clinical practice variation.

Nationwide Children’s Hospital developed a QI project titled "improving care through standardized treatment of spontaneous pneumothorax" in an attempt to standardize the care of pediatric patients with primary spontaneous pneumothorax (PSP) and decrease the length of stay and unnecessary radiation exposure.

Protocol:

Resources:

Stakeholders:

Challenges and solutions:

  • One of the challenges we faced was consistent proper performance of aspiration with the high turnover in house staff. All fellows were educated on the proper steps of aspiration, and a detailed guide to the steps of the process was included in the pocket card handout, as well as an online version (available on our hospital intranet widely used by trainees).
  • Reeducation may be important due to the complexity of the pathway and rare nature of spontaneous pneumothoraces.

Links to published data (used to develop the protocol): [1][2][3][4][5][6][7]

Submitted by: Dr. Brian Kenney

The Midwest Pediatric Surgery Consortium (MWPSC) conducted a pilot study to assess the simple aspiration technique as a primary means of initial treatment of PSP in comparison to chest tube insertion or primary surgical intervention (i.e., video-assisted thoracoscopic surgery, VATS). It was developed as a multi-institutional prospective study in which participants were stratified and followed according to surgeon and patient preference into the three groups: simple aspiration, chest tube insertion, primary VATS. Those in the simple aspiration group followed a strict established management protocol and data was collected on the success or failure of the procedure and recurrence. Those in the non-aspiration group were followed prospectively for data collection only. A 1-year telephone survey was completed for all participants.

Protocol:

Resources:

Stakeholders: pediatric surgical team, ED providers, interventional radiology team, radiology nursing staff, patients and families

Challenges and solutions:

  • It may be difficult to accrue enough surgeons willing to provide simple aspiration as a means of initial therapy to patients.
  • There will need to be an interdepartmental understanding of the protocol and agreements with an observation period, especially if the patient’s location resides in the ED.

Links to published data (used to develop the protocol):

Submitted by: Dr. Charles M. Leys

At the Children’s Hospital of Philadelphia, an individual surgeon’s effort resulted in the design of a protocol for the management of PSP that encompasses the services and steps of efficient management.

Protocol:

Resources:

Stakeholders: pediatric surgical team, ED providers, interventional radiology team, patients, and families

Challenges and solutions: implementation of a protocol with complete departmental agreement.

Links to published data (used to develop the protocol):

Submitted by: Dr. Peter Mattei

Texas Children’s Hospital developed an algorithm established by the evidence-based outcomes center which includes a flow diagram regarding the decision points surrounding the management of PSP.

Protocol: Texas Children’s Hospital Spontaneous Pneumothorax Algorithm

Resources:

Stakeholders: pediatric surgical team, ED providers, interventional radiology team, patients, and families

Challenges and solutions: the protocol is limited to the management of the initial presentation for spontaneous pneumothorax and does not include recommendations for recurrence or for persistence despite conservative therapy.

Links to published data (used to develop the protocol):

Submitted by: Dr. Raphael Sun

Recent Research

For recent research pertaining to the management of patients with spontaneous pneumothorax, please refer to references [4][8][9][10][11][12][13][14].

References

  1. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001;119(2):590-602.  [PMID:11171742]
  2. Cunningham JP, Knott EM, Gasior AC, et al. Is routine chest radiograph necessary after chest tube removal? J Pediatr Surg. 2014;49(10):1493-5.  [PMID:25280653]
  3. Laituri CA, Valusek PA, Rivard DC, et al. The utility of computed tomography in the management of patients with spontaneous pneumothorax. J Pediatr Surg. 2011;46(8):1523-5.  [PMID:21843718]
  4. Leys CM, Hirschl RB, Kohler JE, et al. Changing the Paradigm for Management of Pediatric Primary Spontaneous Pneumothorax: A Simple Aspiration Test Predicts Need for Operation. J Pediatr Surg. 2020;55(1):169-175.  [PMID:31706614]
  5. MacDuff A, Arnold A, Harvey J, et al. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65 Suppl 2:ii18-31.  [PMID:20696690]
  6. Noppen M. Spontaneous pneumothorax: epidemiology, pathophysiology and cause. Eur Respir Rev. 2010;19(117):217-9.  [PMID:20956196]
  7. Robinson PD, Cooper P, Ranganathan SC. Evidence-based management of paediatric primary spontaneous pneumothorax. Paediatr Respir Rev. 2009;10(3):110-7; quiz 117.  [PMID:19651381]
  8. Lewit RA, Tutor A, Albrecht A, et al. Pediatric Spontaneous Pneumothorax: Does Initial Treatment Affect Outcomes? J Surg Res. 2021;259:532-537.  [PMID:33189361]
  9. Lawrence AE, Huntington JT, Savoie K, et al. Improving care through standardized treatment of spontaneous pneumothorax. J Pediatr Surg. 2021;56(1):55-60.  [PMID:33139032]
  10. Sudduth CL, Shinnick JK, Geng Z, et al. Optimal surgical technique in spontaneous pneumothorax: a systematic review and meta-analysis. J Surg Res. 2017;210:32-46.  [PMID:28457339]
  11. Brown SGA, Ball EL, Perrin K, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. N Engl J Med. 2020;382(5):405-415.  [PMID:31995686]
  12. Soler LM, Raymond SL, Larson SD, et al. Initial primary spontaneous pneumothorax in children and adolescents: Operate or wait? J Pediatr Surg. 2018;53(10):1960-1963.  [PMID:29361279]
  13. Gariépy M, Beaunoyer M, Miron MC, et al. Management and recurrence of spontaneous pneumothorax in children. Paediatr Child Health. 2020;25(2):86-92.  [PMID:33390745]
  14. Joharifard S, Coakley BA, Butterworth SA. Pleurectomy versus pleural abrasion for primary spontaneous pneumothorax in children. J Pediatr Surg. 2017;52(5):680-683.  [PMID:28168984]
Last updated: March 18, 2022