Charles M Leys1, Ronald B Hirschl2, Jonathan E Kohler3, Linda Cherney-Stafford3, Nicholas Marka3, Mary E Fallat4, Samir K Gadepalli2, Jason D Fraser5, Julia Grabowski6, R Cartland Burns7, Cynthia D Downard4, David S Foley4, Devin R Halleran8, Michael A Helmrath9, Rashmi Kabre6, Michelle S Knezevich10, Dave R Lal10, Matthew P Landman7, Amy E Lawrence8, Grace Z Mak11, Peter C Minneci8, Ninette Musili2, Beth Rymeski9, Jacqueline M Saito12, Thomas T Sato10, Shawn D St Peter5, Brad W Warner12, Daniel J Ostlie13. 1. Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI. Electronic address: Leys@surgery.wisc.edu. 2. Division of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI. 3. Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI. 4. Division of Pediatric Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, KY. 5. Division of Pediatric Surgery, Department of Surgery, Children's Mercy Hospital, Kansas City, MO. 6. Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. 7. Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. 8. Center for Surgical Outcomes Research, Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH. 9. Division of Pediatric Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH. 10. Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI. 11. Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine and Biologic Sciences, Chicago, IL. 12. Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO. 13. Department of Surgery, Phoenix Children's Hospital, Phoenix, AZ.
Abstract
PURPOSE: Chest tube (CT) management for pediatric primary spontaneous pneumothorax (PSP) is associated with long hospital stays and high recurrence rates. To streamline management, we explored simple aspiration as a test to predict need for surgery. METHODS: A multi-institution, prospective pilot study of patients with first presentation for PSP at 9 children's hospitals was performed. Aspiration was performed through a pigtail catheter, followed by 6 h observation with CT clamped. If pneumothorax recurred during observation, the aspiration test failed and subsequent management was per surgeon discretion. RESULTS: Thirty-three patients were managed with simple aspiration. Aspiration was successful in 16 of 33 (48%), while 17 (52%) failed the aspiration test and required hospitalization. Twelve who failed aspiration underwent CT management, of which 10 (83%) failed CT management owing to either persistent air leak requiring VATS or subsequent PSP recurrence. Recurrence rate was significantly greater in the group that failed aspiration compared to the group that passed aspiration [10/12 (83%) vs 7/16 (44%), respectively, P=0.028]. CONCLUSION: Simple aspiration test upon presentation with PSP predicts chest tube failure with 83% positive predictive value. We recommend changing the PSP management algorithm to include an initial simple aspiration test, and if that fails, proceed directly to VATS. TYPE OF STUDY: Prospective pilot study LEVEL OF EVIDENCE: Level III.
PURPOSE: Chest tube (CT) management for pediatric primary spontaneous pneumothorax (PSP) is associated with long hospital stays and high recurrence rates. To streamline management, we explored simple aspiration as a test to predict need for surgery. METHODS: A multi-institution, prospective pilot study of patients with first presentation for PSP at 9 children's hospitals was performed. Aspiration was performed through a pigtail catheter, followed by 6 h observation with CT clamped. If pneumothorax recurred during observation, the aspiration test failed and subsequent management was per surgeon discretion. RESULTS: Thirty-three patients were managed with simple aspiration. Aspiration was successful in 16 of 33 (48%), while 17 (52%) failed the aspiration test and required hospitalization. Twelve who failed aspiration underwent CT management, of which 10 (83%) failed CT management owing to either persistent air leak requiring VATS or subsequent PSP recurrence. Recurrence rate was significantly greater in the group that failed aspiration compared to the group that passed aspiration [10/12 (83%) vs 7/16 (44%), respectively, P=0.028]. CONCLUSION: Simple aspiration test upon presentation with PSP predicts chest tube failure with 83% positive predictive value. We recommend changing the PSP management algorithm to include an initial simple aspiration test, and if that fails, proceed directly to VATS. TYPE OF STUDY: Prospective pilot study LEVEL OF EVIDENCE: Level III.