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Spontaneous Pneumothorax in Children: National Management Strategies and

Outcomes

Article  in  Journal of Laparoendoscopic & Advanced Surgical Techniques · December 2017

DOI: 10.1089/lap.2017.0467

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 JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
Volume 28, Number 2, 2018
ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2017.0467

Spontaneous Pneumothorax in Children:

National Management Strategies and Outcomes

Kibileri Williams, MD,1,2 Tolulope A. Oyetunji, MD, MPH,3 Grace Hsuing, MD,1,2
Richard J. Hendrickson, MD,3 and Timothy B. Lautz, MD1,2
Downloaded by Childrens Mercy Hospital from online.liebertpub.com at 02/19/18. For personal use only.

Abstract

Introduction: The timing of surgical intervention in the management of spontaneous pneumothorax remains
controversial. The aim of this multicenter review was to compare management strategies and outcomes in
children with spontaneous pneumothorax.
Methods: We retrospectively reviewed patients 10–19 years old in the Pediatric Health Information System
admitted for spontaneous pneumothorax from 2010 to 2014. Three treatment groups were identified based on initial
hospital management—no intervention, initial chest tube placement, and operation; and outcomes were compared.
Results: A total of 1040 patients were included. The majority were male (82.1%) and White (71.1%). The mean
age at first encounter was 15.7 – 1.7 years. Initial treatment included no intervention in 336 (32.3%), chest tube
in 497 (47.8%), and video-assisted thoracoscopic surgery (VATS) in 207 (19.9%). Ultimately, 417 (40.1%)
patients underwent VATS during the initial admission and 559 (53.8%) during the initial admission or a
subsequent encounter. Aggregate length of stay (LOS) was highest for those treated initially with chest tube
alone (P < .001). For patients managed initially with chest tube, the probability of requiring surgery increased
with each day of hospitalization. Initial operation was associated with a decreased risk of readmission (OR 0.67,
95% CI 0.50–0.90). Estimated adjusted hospital costs, aggregated across all encounters, were highest for chest
tube alone (P < .001).
Conclusion: Early VATS is associated with decreased hospital LOS, charges, and readmissions. For those
managed initially with chest tube alone, the likelihood of requiring operation increases with each day hospi-
talized, and early conversion to operative management should be considered in patients with persistent pneu-
mothorax or air leak.

Keywords: pneumothorax, spontaneous pneumothorax, pediatric

Introduction to children.2 The effectiveness of surgery in preventing

recurrence and the timing of intervention also remain con-

S pontaneous pneumothorax affects 3.4 per 100,000

children less than 18 years of age and occurs more fre-
quently in males with a tall, thin body habitus.1 Primary
spontaneous pneumothorax (PSP) refers to cases that occur
without a precipitating cause and is thought to result from
alveolar rupture in patients with emphysematous changes at
the lung apices (commonly referred to as blebs).1
There are no evidence-based pediatric-specific guidelines
for the management of spontaneous pneumothorax and it
remains unclear whether adult guidelines are applicable
troversial. There are three general approaches to the initial
management of a patient with spontaneous pneumothorax—
no intervention, drainage through needle aspiration or chest
tube placement, or immediate operation, most commonly in
the form of video-assisted thoracoscopic surgery (VATS).
Single-institution retrospective reviews have shown that
nonoperative management is associated with a recurrence
rate as high as 57%3–6 and that shorter length of stay (LOS) is
achieved when surgery is performed initially rather than
after failure of nonoperative management.4,7 In contrast,

1
Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois.
2
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
3
Department of Surgery, Children’s Mercy Kansas City, Kansas City, Missouri.
The abstract of this article was presented at IPEG’s 26th Annual Congress for Endosurgery in Children in London, England on July 19–
22, 2017.

218
 SPONTANEOUS PNEUMOTHORAX IN CHILDREN
there are costs and potential complications associated with
VATS and a nontrivial recurrence rate even after surgery, so
many clinicians prefer a conservative management approach
for initial episodes. The majority of patients currently un-
dergo initial nonoperative management with chest tube
placement alone.7
Given the limitations of single-institution reviews, this
study aims to compare outcomes and resource utilization
among patients with spontaneous pneumothorax who un-
derwent nonoperative management, chest tube placement, or
operation within the initial 24 hours of admission using a
large national database. A secondary aim is to determine the
likelihood of operation before discharge for each consecutive
day of hospitalization for nonoperative therapy. We hy-
pothesized that recurrence, readmission, and resource utili-
zation would be lowest in those who had early operation and
that the likelihood of surgery before discharge for patients
managed initially with chest tube alone increases with each
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day they remain hospitalized.
Methods
Data for this study were obtained from the Pediatric Health
Information System (PHIS), an administrative database that
contains inpatient, emergency department, ambulatory surgery,
and observation encounter-level data from over 45 not-for-profit,
tertiary care pediatric hospitals in the United States. These
hospitals are affiliated with the Children’s Hospital Association
(Overland Park, KS). Data quality and reliability are assured
through a joint effort between the Children’s Hospital Asso-
ciation and participating hospitals. Portions of the data submis-
sion and data quality processes for the PHIS database are
managed by Truven Health Analytics (Ann Arbor, MI). For the
purposes of external benchmarking, participating hospitals pro-
vide discharge/encounter data, including demographics, diag-
noses, and procedures. Nearly all of these hospitals also submit
resource utilization data (e.g., pharmaceuticals, imaging, and
laboratory) into PHIS. Data are deidentified at the time of data
submission, and data are subjected to a number of reliability and
validity checks before being included in the database. For this
study, data from 45 hospitals were included. Institutional Re-
view Board exemption was obtained for this study from the
Ann & Robert H. Lurie Children’s Hospital of Chicago.
In this study all patients aged 10–19 years old with a di-
agnosis of spontaneous pneumothorax from January 1, 2010
to December 31, 2014 were included. The International
Classification of Diseases, Ninth Revision (ICD-9) codes
used to identify spontaneous pneumothorax were 512.0,
512.81, 512.83, and 512.89. Procedures/operations were
captured using ICD-9 procedure codes: 34.04, 32.20, 32.21,
32.29, 32.3, 32.39, 34.51, 34.59, 34.52, 34.29, 34.28, 34.6,
and 34.21. Chest tube placement based on ICD-9 procedure
code (34.04) was found to be incomplete and was therefore
captured using either the ICD-9 code or Clinical Transaction
of Care (CTC) code for chest tube or Pleur-evac. Hospitals
were excluded from analysis if PHIS captured supply charges
for Pleur-evac or chest tube placement in <10% of cases.
Chest computed tomography scan (CT scan) utilization was
identified using ICD-9 procedure code (87.41) or imaging
CTC codes (4330–4339, 4399 with technique = 51).
Demographic data were extracted, including age, sex, race,
and ethnicity. Comorbidities were also identified. The pri-
219
mary outcome measure was surgery either during the initial
admission or a subsequent encounter. Secondary outcome
measures included CT utilization, LOS, readmissions (in-
cluding both emergency department and inpatient visits),
reoperations, and total hospital estimated costs. Patients were
analyzed according to the initial management strategy during
hospital day 0 or 1 into three groups—no intervention, chest
tube alone, or operation (VATS). Descriptive analysis of
demographic data was performed and reported as means,
medians, and frequencies. Univariate analysis was performed
using chi-square test or analysis of variance. Multivariate
analysis was performed to test the association of read-
missions with initial operation using a logistic regression
controlling for comorbidities and chest CT scan utilization.
For patients who underwent initial chest tube placement, the
cumulative chance of requiring operation was calculated for
each day that patients remained hospitalized. IBM SPSS
Statistics for Windows, version 24, was used for analysis, and
a P value <.05 was considered statistically significant.
Results
Patient characteristics
A total of 1040 patients from 36 pediatric hospitals had an
inpatient admission for spontaneous pneumothorax meeting
inclusion criteria during the study period, 2010–2014. The
majority of patients were male (82.1%), White (71.1%), and
non-Hispanic (84.8%). The mean age at first encounter was
15.7 – 1.7 years (median 16). Most patients (68.2%) were
admitted through the emergency department on their first
encounter. Comorbidities included asthma in 129 (12.4%)
and cystic fibrosis in 29 (2.8%).
Initial treatment (on hospital day 0 or 1) included no in-
tervention in 336 (32.3%), chest tube in 497 (47.8%), and
operation in 207 (19.9%). Ultimately, 417 (40.1%) had sur-
gery during the initial admission and 559 (53.8%) either
during the initial admission or a subsequent encounter.
CT scan utilization
During their first encounter, 334 (32.1%) patients had a CT
scan. There was no difference in CT scan utilization between
the three initial treatment groups. However, among patients
who had a CT, 185 (55.4%) underwent an operation during
the initial encounter compared to 232 (32.9%) who did not
have a CT (P p .001). The readmission rate was no higher for
patients who did not have a CT during their initial admission
(23.7%) compared to those who did undergo CT (26.2%)
(P = .40).
Length of stay
Initial hospital LOS was longer with either interven-
tion (chest tube or operation) compared to no-intervention
(P < .001). When analyzing aggregate LOS over all en-
counters for pneumothorax, the LOS was similar in those
treated initially with operation or no-intervention, but higher
for those treated initially with chest tube alone (P < .001)
(Table 1).
Likelihood of surgery by hospital day
Among the 497 patients managed with chest tube alone in
the first 24 hours, 157 (31.6%) underwent operation at some
 220
Table 1. Outcomes Among Patients with Spontaneous Pneumothorax
According to Initial Management in the First 24 Hours
Initial management (first 24 hours)
No intervention (n = 336)
Surgery during admission, n (%)
Initial admission 53 (15.8)
All admissions 105 (31.3)
Length of stay, mean (SD), day
Initial admission 4.1 (4.3)
All admissions 6.5 (8.5)
Readmissions, n (%) 82 (24.4)
Adjusted costs, $
Initial admission 10,046
All admissions 16,523
VATS, video-assisted thoracoscopic surgery.
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point before discharge. These operations were performed on
hospital day 2 in 29 (18.5%), day 3 in 33 (21.0%), day 4 in 21
(13.4%), day 5 in 22 (14.0%), and day 6–30 in 52 (33.1%).
For patients managed initially with chest tube alone, the
probability of requiring surgery was 36% if they remained
hospitalized on day 3, 46% on day 4, 55% on day 5, and 62%
on day 6 (Fig. 1).
Readmissions
Patients who were treated with initial operation within
24 hours had a trend toward lower readmission rate than those
treated nonoperatively or with chest tube alone but this was
not statistically significant on univariate analysis (P = .08)
(Table 1). However, among those who received an opera-
tion during the first admission (regardless of timing), the
readmission rate was 87/417 (20.9%) compared to 177/623
(28.4%) among those who did not (P = .007). In a multivar-
iable logistic regression, controlling for patient risk factors
(asthma and cystic fibrosis), as well as for CT scan utilization,
operation during the first encounter was associated with a
decreased risk of readmission (OR 0.67, 95% CI 0.50–0.90).
FIG. 1. Probability of undergoing operative intervention
for patients managed initially with chest tube who remain
hospitalized on each respective day.
WILLIAMS ET AL.
Chest tube (n = 497) VATS (n = 207) P
157 (31.6) — <.001
247 (49.7) — <.001
7.2 (7.3) 6.2 (4.0) <.001
9.6 (9.1) 7.4 (5.0) <.001
140 (28.2) 42 (20.3) .08
18,021 17,011 <.001
24,178 20,374 <.001
Reoperation rate
Among those treated initially with operation, the re-
operation rate was 9 (4.3%) during the initial encounter and
28 (13.5%) across all readmission encounters. Laterality
could not be determined in the PHIS database, so a fraction of
these reoperations were likely on the contralateral side.
Hospital costs
Estimated adjusted hospital costs, aggregated across the
initial and readmission encounters, were $16,523 for no in-
tervention, $24,178 for chest tube alone, and $20,374 for
operation (P < .001) (Table 1).
Discussion
This study has shown that most patients with spontaneous
pneumothorax undergo chest tube placement as initial man-
agement in the first 24 hours, but the majority will ulti-
mately require surgical intervention. The readmission rate
was lowest in those who had an operation during the first
admission, and total hospital LOS across all admissions was
longest in those who had chest tube placement alone. This
study also showed that the likelihood of surgery increases
with each day of hospitalization for those managed with chest
tube alone.
The majority of patients in this analysis, as in prior studies,
underwent initial nonoperative management. In a single in-
stitution review by Qureshi et al., nonoperative treatment was
attempted in 37 of 51 pneumothoraces, 20 of which recurred
requiring VATS.4 In a similar review by Lopez et al., 98 of
108 pneumothoraces were initially managed conservatively,
with a recurrence rate of 40%.7 Initial nonoperative man-
agement was performed in 80% of patients in our population,
including 336 who received no intervention and 497 who
underwent chest tube placement.
CT scan utilization in the current study was highly vari-
able, reflecting the controversy over the value that it adds for
clinical decision-making. There was no difference in CT
utilization among patients treated initially with no interven-
tion, chest tube, or VATS. However, patients who underwent
CT were more likely to undergo surgery before discharge.
Fewer than one-third of patients underwent CT, which is
 SPONTANEOUS PNEUMOTHORAX IN CHILDREN
lower than rates reported in studies of adults with PSP.2,8 The
rationale for avoiding CT in children cannot be determined,
but may include a desire to avoid ionizing radiation in
children or a belief that CT findings do not affect clini-
cal decision-making. Clinicians favoring CT in the initial
workup argue that it can identify blebs in the contralateral
lung, which can guide patient/parent counseling regarding
recurrence, and also that it rules out secondary pathological
conditions, which may have caused the pneumothorax.2 In
one review, 40% of those with contralateral disease on CT
developed a pneumothorax in the subsequent 6 months.2
However, it is still not clear whether this mandates inter-
vention if the patient is asymptomatic on that side. Further-
more, since histology confirms blebs in nearly all patients
who undergo operative intervention,2 there seems to be
limited utility in demonstrating blebs preoperatively. In
another review by Laituri et al., almost 80% of patients with
negative scans were found to have blebs intraoperatively
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suggesting that the sensitivity of CT for detecting blebs is
low.8 Some investigators have suggested that the presence of
blebs on CT is predictive of ipsilateral recurrence, whereas in
other studies this has not held true.9,10
The correlation between initial management and hospital
LOS is also poorly understood. While most patients remain
hospitalized for several days following operative manage-
ment, this is counterbalanced by the hospital days associated
with persistent air leak in patients managed with chest tube
alone. In a review of the literature by Chambers and Scarci,
VATS was associated with decreased LOS compared to chest
tube drainage alone.3 Similarly, Lopez et al. found that initial
nonoperative management was associated with increased
LOS compared to primary surgery.7 Qureshi et al. found that
total treatment LOS was shorter for primary VATS compared
to VATS done only after recurrence.4 Our study showed that
total hospital LOS across all encounters for spontaneous
pneumothorax was highest in those who had chest tube alone
as initial management. Persistent air leakage after chest tube
placement likely contributes to the increased LOS. The def-
inition of a persistent air leak ranges in the literature from 3 to
5 days7,11,12 and there are no evidence-based guidelines on
the duration of air leak after which operative intervention is
required. O’Lone et al. suggested that surgical intervention is
likely to be required for a leak persisting for longer than
5 days,11 while Granke et al. suggest earlier intervention at
3 days.12 However, persistent air leakage signaling failure of
nonoperative management has been identified as a factor
associated with proceeding to surgery.7,13,14 A decision for
early operation in patients with persistent air leak after chest
tube placement may reduce the period of preoperative hos-
pitalization and total cost. This study has also demonstrated
the likelihood of surgical intervention increases with each
day that patients with a chest tube remain hospitalized, fur-
ther underscoring the rationale for earlier definitive surgical
intervention.
A multitude of factors have been reported to correlate with
recurrence risk, including initial management approach, pa-
tient factors, and operative technique. Our findings correlate
with prior reports demonstrating a reduced recurrence risk in
children who undergo VATS compared to nonoperative
management. Lopez et al. found a recurrence rate of 40%
after nonoperative management compared to 15% after sur-
gery.7 Similarly Noh et al. demonstrated lower recurrence
221
rates after surgery compared with observation or chest tube
placement and interestingly found that recurrence was higher
in younger age groups, particularly those less than 16 years
old.15 Other studies have also found that younger age is
associated with higher recurrence rates.16,17 The correla-
tion between operative technique and recurrence rates re-
mains very controversial. Different surgeons utilize various
approaches, including combinations of wedge resection,
pleurectomy, pleural abrasion, chemical pleurodesis, and
staple line covering. In a systematic review of 51 studies by
Sudduth et al., wedge resection and chemical pleurodesis,
with or without pleural abrasion, were associated with
the lowest recurrence rate,18 while Joharifard et al. found
lower recurrence rates with pleurectomy compared to
pleural abrasion.19
Differences in LOS, recurrence, and operative utilization
in the different management groups all contribute to variation
in costs and charges. Our study examined aggregate esti-
mated costs across all encounters for spontaneous pneumo-
thorax and found significantly higher costs associated with
initial management by chest tube alone. This was attributed
to longer hospital stay and eventual need for surgery in those
who were initially managed nonoperatively. In a cost-benefit
analysis of primary versus delayed VATS for spontaneous
pneumothorax, Qureshi et al. found that the charges associ-
ated with primary versus delayed VATS were not signifi-
cantly different, but that if the charges for surgery on the 46%
of patients who did not recur were considered, performing
primary VATS on all patients would increase the total
charges by $4010 per patient.4 Cook et al. also concluded that
it was most cost-effective to perform surgery only after the
first recurrence of spontaneous pneumothorax and not on the
initial admission.6 However, both these studies, like ours,
used charge data, which does not always accurately reflect
actual hospital costs. Lopez et al., using direct measures of
cost, found that initial nonoperative management had lower
median direct costs than initial surgery, but that there was no
difference in cost between primary and delayed surgery.7
Given that LOS influences cost in the earlier resource-
intensive periods of hospitalization,20 we believe that earlier
surgical intervention on the first admission for those who are
more likely to fail nonoperative management may serve to
lower overall expenditure.
We acknowledge the limitations of this study. Inherent to
the retrospective examination of an administrative database
is the lack of clinical data on such factors as provider
decision-making and the clinical status of the patient, which
may have influenced the decision to intervene surgically. We
were unable to determine which patients may have had a
persistent air leak or residual pneumothorax on imaging,
factors that influence clinical decision-making. Similarly, the
database does not provide historical information on whether
this was the first episode of pneumothorax in the patients
included. Furthermore, this study only captured data from
children’s hospitals which participate in PHIS. Adolescents
with PSP are frequently treated at adult institutions, where
management patterns may be very different. As such, the
generalizability of our findings is restricted. Likewise, an
unknown proportion of these patients may grow out of pe-
diatric care and transition to adult institutions so that they are
lost to pediatric follow-up, which may affect the accurate
assessment of recurrence rates.
 222
Despite these limitations, we believe that this study high-
lights the management and associated outcomes of sponta-
neous pneumothorax on a national level, providing evidence
favoring earlier identification and surgical intervention for
those patients who are likely to fail nonoperative manage-
ment. Determining the factors that allow providers to identify
these patients within the first few days of admission would
facilitate earlier intervention and should be a focus of future
prospective studies.
Conclusion
Many children with small pneumothoraces do well with
no intervention. For those requiring any intervention, the
majority ultimately requires VATS. Early VATS decreases
hospital LOS, charges, and readmissions. For those managed
initially with chest tube alone, the likelihood of requiring
operation increases with each day hospitalized and early
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conversion to operative management should be considered.
Acknowledgments
The authors express sincere gratitude to the members of
the Pediatric Health Research Outcomes Group for Surgery at
Ann & Robert H Lurie Children’s Hospital of Chicago for
assistance in data analysis. This research did not receive any
specific grant from funding agencies in the public, commer-
cial, or not-for-profit sectors.
Authors’ Contributions
T.A.O. and T.B.L. conceptualized the project, performed
data analysis, and supervised the preparation of the article.
K.W. was the primary author of the article. G.H. performed
data analysis and drafting of the article. R.J.H., T.B.L., and
T.A.O. provided final editing of the article.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Timothy B. Lautz, MD
Department of Pediatric Surgery
Ann & Robert H. Lurie Children’s Hospital of Chicago
225 East Chicago Avenue, Box 63
Chicago, IL 60611
E-mail: tlautz@luriechildrens.org