Case Report Respirology Mo (English)

PNEUMOTHORAX IN CHILDREN Case Report
CASE REPORT
RESPIROLOGY DIVISION
SECONDARY SPONTANEOUS PNEUMOTHORAX IN CHILDREN
Mokhammad Ikhsan Nurkholis
Department of Child Health, Medical School, Hasanuddin University /

Wahidin Sudirohusodo General Hospital, Makassar, Indonesia
INTRODUCTION
Pneumothorax is defined as the presence of air or gas in the pleural cavity (ie,
the potential space between the visceral and parietal pleura of the lung), which can
impair oxygenation and/or ventilation. The clinical results are dependent on the
degree of collapse of the lung on the affected side. If the pneumothorax is significant,
it can cause a shift of the mediastinum and compromise hemodynamic stability. Air
can enter the intrapleural space through a communication from the chest wall (ie,
trauma) or through the lung parenchyma across the visceral pleura.1
A primary pneumothorax is one that occurs without an apparent cause and in
the absence of significant lung disease, while a secondary pneumothorax occurs in
the presence of existing lung pathology. In a minority of cases, the amount of air in
the chest increases markedly when a one-way valve is formed by an area of
damaged tissue, leading to a tension pneumothorax. This condition is a medical
emergency that can cause steadily worsening oxygen shortage and low blood
pressure. Unless reversed by effective treatment, these sequelae can progress and
cause death.2
The incidence of spontaneous pneumothorax is 18 per 100,000 men per year
and 6 per 100,000 women per year. It occurs most often in the 20s, and primary
spontaneous pneumothorax rarely occurs over the age of 40. Secondary
spontaneous pneumothorax occurs at any ages. Between 1991 and 1995 the rate of
admissions to United Kingdom hospitals for both primary and secondary
spontaneous pneumothorax was 16.7 per 100,000 men per year and 5.8 per
100,000 women per year. 3
Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 1

The main purpose of treatment pneumothorax is to remove the air from the
pleural space and prevent relapses. Simple observation, needle aspiration and chest
drain are all possibilities and the choice will depend upon the severity of the
condition. There is much national and international controversy surrounding the
'right' initial treatment of pneumothoraces. Generally, the more symptomatic the
patient, the more active intervention should be utilised. Large pneumothoraces
should be drained, even if there are minimal or no symptoms, as this speeds the
resolution. Needle aspiration is still favoured as the initial treatment of
pneumothoraces, but in case of secondary spontaneous pneumothorax and
traumatic pneumothorax usually require active treatment. Iatrogenic pneumothorax
does not normally require a chest drain and tension pneumothorax requires
immediate attention.5
This paper will report a case of secondary spontaneous pneumothorax in 14

years and 8 month old girl.
CASE REPORT
A-14 years and 8 month old girl, admitted to pediatric department of
dr.Wahidin Sudirohusodo Hospital on November 13, 2012.
History taking
Her main complaint was sudden onset of shortness breath, experienced since
six hours prior to the admission. She felt chest pain and paroxysmal cough for one
week. There was history of frequent cough for three month, slimy but no dyspnea
appearance. No fever and seizure complaint on admission, but there was history of
frequent fever for three months prior to admission. She felt nausea and vomiting two
times. Her appetite was decreased. Defecation and micturition were normal. Body
weight decreased for the last three months. She was complaint a bed time sweating
for the last one month. There was no contact history with adult tuberculosis patients.
History of the chest trauma was denied. There was no contact history with suddenly
died poultry.

Physical examination
On physical examination revealed:

General condition: She is severely ill, nutrition status is under nourish, and
conscious state is compos mentis (GCS 15: E4M6V5). Blood pressure (BP) 90/60
mmHg. Pulse rate (PR) 120x/menit. Respiration rate (RR) 60x/menit. Body
temperature (BT) 37.80C. Body weight (BW) 13 kg. Body length (BL) 96 cm. She
looks distressed and sweating. No pale and cyanotic appearances, nostril breathing
was noted. Chest respiratory movement is assymetrical, there is retraction on
suprasternal and subcostal area. Percussion reveals hyper-resonance (hyper-sonor)
over the collapse lung. Breath sounds are reduced or absent over the affected area
(left side). Crackles are found on the right lung, there is no wheezing appearance.
On palpation examination found crepitations on the left lung. Solitary and regular
heart sound with no murmur heard. Peristaltic are normal, liver and spleen are not
palpable. BCG vaccine scar was found on the left upper arm.
Laboratory examination
Complete blood count:

White blood count 9.560 /mm3 MCV 84.4 fl
Red blood count 4.54 x106 /mm3 MCH 28.0 pg
Hemoglobin 12.7 g/dl3 MCHC 33.2 g/dl
Hematocrit 38.3 % Platelet count 317.000 /mm3
Blood gas analysis:

pH 7.454
PO2 61.2 mmHg
PCO2 30.8 mmHg
SO2 92.2 %
HCO3 21.2 mmol/L
BE -1.9 mmol/L
Result: Fully compensated of respiratory alkalosis.

Blood glucose level 108 mg/dl

SGOT 14 U/L
SGPT 8 U/L
HBsAg (Rapid) negative
Anti HCV negative
Bleeding time 800 minutes
Clothing time 200 minutes
Prothrombin time 10.9 second
Activated Partial Thromboplastin Time 27.3 second
Electrolytes: Sodium 144 mmol/l, potassium 4.1 mmol/l, chloride 112 mmol/l.
Antero Posterior chest X-ray result: CT Scan Thorax result:

Left pneumothorax Left pneumothorax with lung
Lung tumor suspected colaps
Infected bronchiectasis dextra
Advice : Thorax CT scan Chronic active of duplex
tuberculosis
Figure 1. Patient thorax x-ray Figure 2. Patient thorax CT scan

Working Diagnosis:
Left Pneumothorax
Lung tuberculosis suspected
Under nourish
Managements
Supporting therapy:
O2 2 L/min via nasal canule
Intra Venous Fluid Displacement Dextrose 5% 30 gtt/min
Medicamentosa:
Ceftriaxon injection 2 x 1 g/iv
Ketorolac injection 2 x 10 mg/iv
Ranitidine injection 2 x 25 mg/iv
Diet therapy:
Usual diet
o Calorie 2000 gr
o Protein 75 gr
Planning
Consult to surgical department for water sealed drainage (WSD) procedure.
Tuberculin test
FURTHER OBSERVATIONS
2nd day of treatment (14 November 2012)
General condition: weak
BP 90/60 mmHg, RR 50x/mnt, PR 140x/mnt, BT 37.0 0C
Fever and headache was absent. Cough, mucus and shortness of breath was
positives.. On physical examination nostril breathing and suprasternal retractions still
appear. Asymmetrical movement of the chest wall when breathing was noted. On
chest auscultation found decreased breath sounds on the left lung, crackles are still
audible in right lung. No other new complaints from the patient. O2 2 L/min via nasal
canule, IVFD D5% 30 gtt/mnt, ceftriaxon injection 2 x 1 g/iv, ketorolac injection 2 x 10
mg/iv, ranitidine 2 x 25 mg/iv. Usual dietary intake.
Planning: WSD procedure and Tuberculin test.

3rd day of treatment (15 November 2012)

BP 100/60 mmHg, RR 36 x/mnt, PR 80 x/mnt, BT 36.7 0C
Cough was negative and shortness of breath was reduced. Her appetite still
decreased. On physical examination nostril breathing and suprasternal retractions
still appear. Asymetrical movement of the chest wall when breathing was improved.
On chest auscultation found decreased breath sounds on the left lung, crackles are
audible in both lung. WSD was attached. No other new complaints from the patient.
O2 2 L/min via nasal canule, IVFD D5% 30 gtt/mnt, ceftriaxon injection 2 x 1 g/iv,
ketorolac injection 2 x 10 mg/iv, ranitidine 2 x 25 mg/iv. Usual dietary intake.
Planning: Routine blood test, Read of tuberculin test tomorrow
4th day of treatment (16 November 2012)

Shortness of breath was disappeared. Her appetite was improved. On physical
examination nostril breathing was disappeared and suprasternal retractions was
minimal. Asymetrical movement of the chest wall was disappeared. On chest
auscultation found left lung breath sounds was improved, crackles are audible in
both lung. WSD still attached. No other new complaints from the patient.
IVFD D5% 30 gtt/mnt, ceftriaxon injection 2 x 1 g/iv, ketorolac injection 2 x 10 mg/iv,
ranitidine 2 x 25 mg/iv. Rifampicin 1 x 450 mg/oral, Isoniazid 1 x 300 mg/oral,
Pirazinamid 2 x 250 mg/oral. Usual dietary intake. She refused routine blood test.
Tuberculin test result (+) induration 30 mm.
(Sokal methods)
Figure 3. Positive result of tuberculin test Figure 4. Positive result of tuberculin test
Planning: Continued therapy, Thorax x-ray control


Cough was negative. Shortness of breath was disappeared. Her appetite was good.
On physical examination retractions was dissapeared. Asymetrical movement of the
chest wall was disappeared. On chest auscultation found left lung breath sounds
was normal, crackles are audible in both lung. WSD still attached. No other new
complaints from the patient.
IVFD D5% 30 gtt/mnt, ceftriaxon injection 2 x 1 g/iv, ketorolac injection 2 x 10 mg/iv,
ranitidine 2 x 25 mg/iv. Rifampicin 1 x 450 mg/oral, Isoniazid 1 x 300 mg/oral,
Pirazinamid 2 x 250 mg/oral. Usual dietary intake.
Antero Posterior chest X-ray control result:
Pneumothorax sinistra was dissapeared
Specific bilateral pneumonia infection
Figure 5. Thorax x-ray; before and after treatment
Planning: Continue therapy, Stop chest tube (WSD)

General condition: active
Cough and shortness of breath was negatives. Her appetite was good. On physical
examination retractions was negative. Normal movement of the chest wall. On chest
auscultation breath sounds was normal, crackles are audible in both lung. No other
new complaints from the patient.
Planning: Continue therapy


Vital sign was in normal range.
examination retractions was negative. Symmetrical movement of the chest wall. On
new complaints from the patient. IVFD D5% 30 gtt/mnt, ceftriaxon injection 2 x 1 g/iv,
ketorolac injection 2 x 10 mg/iv, ranitidine 2 x 25 mg/iv. Rifampicin 1 x 450 mg/oral,
Isoniazid 1 x 300 mg/oral, Pirazinamid 2 x 250 mg/oral. Usual dietary intake.

Isoniazid 1 x 300 mg/oral, Pirazinamid 2 x 250 mg/oral. Pyridoxine 2 x 40 mg/oral.
Usual dietary intake. Planning: Continue therapy

Usual dietary intake.


General condition: good
Usual dietary intake. Her mother asking for discharge from hospital and planning to
continue therapy at home.
Planning: Continue oral therapy, stop intravenous therapeutic drug.
Definitive diagnosis
Left spontaneous secondary pneumothorax
Lung tuberculosis
Under nourish
Prognosis
Qua ad vitam : ad bonam
Qua ad sanationem : ad bonam
DISCUSSION
The lungs are a pair of spongy, air-filled organs located on either side of the
chest (thorax). The trachea (windpipe) conducts inhaled air into the lungs through its
tubular branches, called bronchi. The bronchi then divide into smaller and smaller
branches (bronchioles), finally becoming microscopic. The bronchioles eventually
end in clusters of microscopic air sacs called alveoli. In the alveoli, oxygen from the
air is absorbed into the blood. Carbon dioxide, a waste product of metabolism,
travels from the blood to the alveoli, where it can be exhaled. Between the alveoli is
a thin layer of cells called the interstitium, which contains blood vessels and cells that
help support the alveoli.7

The lungs are covered by a thin tissue layer called the pleura. The same kind
of thin tissue lines the inside of the chest cavity -- also called pleura. A thin layer of
fluid acts as a lubricant allowing the lungs to slip smoothly as they expand and
contract with each breath.7
Pneumothorax is defined as the presence of air or gas in the pleural cavity (ie,
the potential space between the visceral and parietal pleura of the lung), which can
impair oxygenation and/or ventilation. The clinical results are dependent on the
degree of collapse of the lung on the affected side. If the pneumothorax is significant,
it can cause a shift of the mediastinum and compromise hemodynamic stability. Air
can enter the intrapleural space through a communication from the chest wall (ie,
trauma) or through the lung parenchyma across the visceral pleura.1
Figure 6: Overview of the lungs in pneumothorax (cited from literature 6)
Pneumothoraces can be classified according to etiology: 4
Primary spontaneous pneumothorax occurs with no previous lung disease but

there are tiny blebs that are foci of weakness. It usually affects a young adult.

Secondary spontaneous pneumo thorax occurs in slightly older subjects with

underlying lung disease. It usually follows rupture of a congenital bulla or a
cyst in chronic obstructive pulmonary disease (COPD).
Traumatic pneumothorax follows a penetrating chest trauma such as a stab
wound, gunshot injury or a fractured rib.
Iatrogenic pneumothorax may follow a number of procedures such as
mechanical ventilation and interventional procedures such as central line
placement, lung biopsy and percutaneous liver biopsy.
Catamenial pneumothorax refers to pneumothorax at the time of
menstruation. The aetiology is endometriosis. It represents 3-6% of
spontaneous pneumothorax in women.
Spontaneous pneumothorax is a commonly encountered problem with

approaches to treatment that vary from observation to aggressive intervention.
Primary spontaneous pneumothorax (PSP) occurs in people without underlying lung
disease and in the absence of an inciting event (see the images below). In other
words, air enters into the intrapleural space without preceding trauma and without an
underlying history of clinical lung disease. However, many patients whose condition
is labeled as primary spontaneous pneumothorax have subclinical lung disease,
such as pleural blebs, that can be detected by CT scanning. Patients are typically
aged 18-40 years, tall, thin, and, often, are smokers.1
Figure 7.* Figure 8.** Figure 9.***
* Radiograph of a patient with a small spontaneous primary pneumothorax

** Close radiographic view of patient with a small spontaneous primary pneumothorax (same patient as from
the previous image).
*** Expiratory radiograph of a patient with a small spontaneous primary pneumothorax (same patient as in
the previous images).

Secondary spontaneous pneumothorax (SSP) occurs in people with a wide

variety of parenchymal lung diseases. These individuals have underlying pulmonary
pathology that alters normal lung structure. Air enters the pleural space via
distended, damaged, or compromised alveoli. The presentation of these patients
may include more serious clinical symptoms and sequelae due to comorbid
conditions.1
There are several methods that can be used in determining the extent of lung
collapse, among others:
1. Summing the furthest distance between the slit pleura on vertical lines, plus the
furthest distance between the slit pleura on the horizontal line, coupled with the
shortest distance between pleural gap on the horizontal line, then divided by
three, and multiplied by ten.9
% estimate size of pneumothorax
A + B + C (cm)
Figure 10: % estimate size of pneumothorax (cited from literature 9)
2. The ratio between the difference hemitoraks broad and extensive lung collapse
hemitoraks divided by the area multiplied by 100%.10
% estimate size of Lung collaps
(AxB) (axb) cm
AxB
Figure 11: % estimate size of Lung collaps (cited from literature 10)

3. If lateral edge of lung is > 2cms from thoracic cage at the level of the hilum, then
this implies pneumothorax is at least 50%. Calculate the ratio of the transverse
radius of the pneumothorax (cubed) to the transverse radius of the hemithorax
(cubed). To express the pneumothorax size as a percentage, multiply the
fractional size by 100. Small pneumothorax is equivalent to <30%.11
Figure 12: % estimate size of pneumothorax (cited from literature 11)
In our case, the calculation of percent area of pneumothorax is 80%, and

percent of collapsed lung area is 20% (estimated calculation with the first method).
Mentioned in an extensive literatures that when the percentage of pneumothorax
>50% and a collapsed lung area is <50%, this mean the patient has a large
pneumothorax. Hence, adequate treatment should be given immediately.9
On physical examination, the suspicious symptom of pneumothorax was
noted. Such as sudden respiratory pain, respiratory distress, chest wall retractions,
asymmetrical respiratory movement, hyper-resonance (hyper-sonor) over the
collapse lung. Breath sounds are reduced or absent over the affected area (left side).
Crackles are found on the right lung, there is no wheezing appearance.1
Chest x-ray or thorax CT scan was the essential investigation to confirm the
presence of pneumothorax. The diagnosis of pneumothorax is established by
demonstrating the outer margin of the visceral pleura (and lung), known as the
pleural line, separated from the parietal pleura (and chest wall) by a lucent gas
space devoid of pulmonary vessels. The pleural line appears in the radiologic image.

On the chest x-ray we evaluate of a typical description such:

The air contain area would seem hiperluscen without lung tissue appereance,
the lung collapse would seem that the line is the edge of the lung, sometimes
a collapsed lung but did not form a line according to the lobe-shaped
pulmonary lobuler.
Lung tissue collapses looked like a radio opaque mass in the hilar region.
Heart and trachea pushed to the healthy side, spatium widened intercostal,
diaphragm down flat and depressed.
When accompanied by blood or fluid, it would seem that a horizontal line is
the boundary between air and liquid.
Figure 13: Pneumothorax chest x-ray; Heart and trachea pushed to the healthy side. (cited from literature 11)
The first chest x-ray examination result in patient was left pneumothorax. The
x-ray image shown a wide hiperluscen area on the left hemithorax. This area was
avaskuler because the lung tissue was collapse. Heart and trachea pushed to the
healthy side, spatium widened intercostal, diaphragm down flat and depressed. The
percent area of pneumothorax as calculated in earlier discussion, concluded that the
patient has a large pneumothorax. Important clinical point of this relationship is that
when there is the presence of a large pneumothorax adequate treatment should be
given immediately.

The principle management of large pneumothorax is:

Stabilized vital sign, close observation and monitoring, and provision of O2.
Reduce the pressure of the thorax by make a connection between the pleural
cavity with outside air.
Investigate directly into the thoracic cavity with thoracoscope, and initiate
WSD with VATS guided. (Video-assisted thoracoscopic ~ surgery)
Thoracotomy and pleurodesis if necessary.
Figure 14: Flowchart of management of spontaneous pneumothorax. (cited from literature 10)
The determination of conservative treatment or surgical intervention is based

on clinical manifestations and confirmed by the results of chest x-ray images. In the
literature one also mentioned that if there are other processes in the lung is an
additional treatment directed against the cause has to be considered. Installation of
water sealed drainage is base on the percent area of pneumothorax > 25% and
intravenous antibiotics are prepare to treat underlying causes of pneumothorax.

Prognosis of the patient are bonam (qua ad vitam and qua ad sanationem)
because adequate management are initiated and clinical symptoms were improved
within a week. Prognosis varies according to the cause of pneumothorax. Secondary
spontaneous pneumothorax had a recurrence rate of 39-47%.
SUMMARY
A case of pneumothorax in a 14 year 8 month old girl, was reported.
Diagnosis was based on history, physical and supporting examinations (chest x-ray,
thorax CT scan and arterial blood gas analysis). The management of this patient is
to remove the trap air with water sealed drainage procedure. Intravenous antibiotic
was given as a prophylaxis therapy for this invasive procedure. As mention that the
patient has a tuberculosis infection, then multidrug therapy for the underlying disease
was prescribed. Intervention and observation evaluated base on improvement of the
clinical symptoms. The prognosis of the patient was good.
Figure 14: Patient with pneumothorax; before water sealed drainage procedure.
Figure 15: Patient with pneumothorax; after water sealed drainage procedure.

Figure 16: Water sealed drainage procedure. (cited from literature 10)
Figure 17: Patient with pneumothorax; first control at OPD (one week after discharge).

REFERENCES
1. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000;342(12):868-74.
2. Tschopp JM, Rami-Porta R, Noppen M, Astoul P. Management of spontaneous
pneumothorax: state of the art. European Respiratory Journal;28(3):63750.
3. Gupta D, Hansell A. Epidemiology of pneumothorax in England. Thorax. 2000 Aug;55:666-71.
4. Korom S, Canyurt H, Missbach A, et al; Catamenial pneumothorax revisited: clinical approach
and systematic review of the literature. J Thorac Cardiovasc Surg. 2004 Oct;128(4):502-8.
5. Kelly AM; Treatment of primary spontaneous pneumothorax. Curr Opin Pulm Med. 2009
Jul;15:376-9.
6. George Schiffman. Pneumothorax (Collapsed Lung). 2012 Nov 05 [cited 2013 June 20].
Available from: http://www.medicinenet.com/pneumothorax/article.htm
7. Mason RM. Lung. Nadel's Textbook of Respiratory Medicine 4th Ed, Elsevier Saunders, 2005.
8. Simon Y. Primary Spontaneous Pneumothorax. 2013 June 10 [cited 2013 June 20]. Available
from: http://www.rch.org.au/clinicalguide/guideline_index/Primary_Spontaneous_Pneumothorax/
9. Conor DC. Quantification of pneumothorax size in radiograph using inter-pleural distances.
AJRad; June 22,1995:1127-30
10. Andrew MD, Anthony Arnold, John Harvey. Management of spontaneous pneumothorax.
British Thoraces Society. 2010 Feb;18-31
11. Henry M, Arnold T. BTS guidelines of spontaneous pneumothorax. Department of Respiratory
Medicine Leeds UK 2003;39-52

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PNEUMOTHORAX IN CHILDREN Case Report

SECONDARY SPONTANEOUS PNEUMOTHORAX IN CHILDREN

Mokhammad Ikhsan Nurkholis

Department of Child Health, Medical School, Hasanuddin University /

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 1

This paper will report a case of secondary spontaneous pneumothorax in 14

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 2

On physical examination revealed:

Complete blood count:

Blood gas analysis:

Result: Fully compensated of respiratory alkalosis.

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 3

Blood glucose level 108 mg/dl

Antero Posterior chest X-ray result: CT Scan Thorax result:

Figure 1. Patient thorax x-ray Figure 2. Patient thorax CT scan

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 4

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 5

3rd day of treatment (15 November 2012)

4th day of treatment (16 November 2012)

Planning: Continued therapy, Thorax x-ray control

5th day of treatment (17 November 2012)

Figure 5. Thorax x-ray; before and after treatment

Planning: Continue therapy, Stop chest tube (WSD)

6th day of treatment (18 November 2012)

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 7

7th day of treatment (19 November 2012)

8th day of treatment (20 November 2012)

9th day of treatment (21 November 2012)

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 8

10th day of treatment (22 November 2012)

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 9

Figure 6: Overview of the lungs in pneumothorax (cited from literature 6)

Pneumothoraces can be classified according to etiology: 4

Primary spontaneous pneumothorax occurs with no previous lung disease but

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 10

Secondary spontaneous pneumo thorax occurs in slightly older subjects with

Spontaneous pneumothorax is a commonly encountered problem with

Figure 7.* Figure 8.** Figure 9.***

* Radiograph of a patient with a small spontaneous primary pneumothorax

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 11

Secondary spontaneous pneumothorax (SSP) occurs in people with a wide

% estimate size of pneumothorax

Figure 10: % estimate size of pneumothorax (cited from literature 9)

% estimate size of Lung collaps

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 12

Figure 12: % estimate size of pneumothorax (cited from literature 11)

In our case, the calculation of percent area of pneumothorax is 80%, and

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 13

On the chest x-ray we evaluate of a typical description such:

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 14

The principle management of large pneumothorax is:

The determination of conservative treatment or surgical intervention is based

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 15

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 16

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 17

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 18

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Figure 7.* Figure 8. Figure 9.*