PEDIATRIC PRIMARY SPONTANEOUS PNEUMOTHORAX

Transcription

1 PEDIATRIC PRIMARY SPONTANEOUS PNEUMOTHORAX Fr patients 1-21 years ld SUSPECTED PNEUMOTHORAX DIAGNOSTIC ALGORITHM Patient with chest pain, dyspnea, hypxia Triage at least level 2 rm patient immediately Evaluatin by MD Unstable: Decreased unilateral breath sunds, respiratry distress, hypxia, hyptensin, tachycardia Stable: Decreased unilateral breath sunds Resuscitate Upright PA CXR Place chest tube (minimum 8fr) r needle decmpressin Less than 1cm frm the chest wall 1-2cm frm the chest wall Mre than 2cm frm the chest wall N chest tube Cnsider chest tube Needs chest tube Admit t surgery service r PICU Nn-reassuring exam and XR Discuss with surgery Observe patient in the ED Less than 4 hurs bs Desn t require chest tube Requires chest tube Repeat Upright PA CXR Reassuring exam and XR Mre than 4 hurs bs ED: Cnsent fr sedatin Surgery: Attending supervises chest tube placement D/C hme Admit t Surgery service with pulmnary fllw Page 1 f 9

2 SUMMARY EVALUATION Histry regarding presentatin: Dcument histry f nset f chest pain r dyspnea Histry f underlying lung disease Histry f trauma Histry f huffing, smking, r breath hlding Histry f prir pneumthrax The unstable patient may present with: Decreased unilateral breath sunds Hyptensin Tachycardia Hypxia LABORATORY STUDIES IMAGING Labratry studies Imaging Nne indicated TREATMENT Upright Psterir/Anterir (PA) chest X-ray (CXR) Patient Stabilizatin in Emergency Department r Urgent Care Resuscitate the unstable patient If the patient is stable and the pneumthrax measures: Less than 1cm N chest tube 1-2cm Discuss insertin f a chest tube with surgery Greater than 2 cm Call surgery t insert a chest tube D/C frm the emergency department if the bservatin perid is less than 4 hurs Admit t the Surgery service if the bservatin perid is greater than 4 hurs regardless if a chest tube was placed Cnsider Vide Assisted Thracscpic Surgery (VATS) r underlying lung disease if the chest tube leak persists fr mre than 3 days Page 2 f 9

3 TABLE OF CONTENTS Algrithm Summary Target Ppulatin Backgrund Definitins Initial Evaluatin and Clinical Management in the Emergency Department (ED)/ Urgent Care (UC) Triage Assessment Mnitring Fluids, Electrlytes, and Nutritin Initial Clinical Exam Treatment in Stable Patient Wh Requires Chest Tube fr Primary Spntaneus Pneumthrax Labratry Studies Medicatins Clinical Management f the patient withut a chest tube Clinical Management f the patient with a chest tube Discharge Instructins Parent Caregiver Educatin-N/A References Clinical Imprvement Team TARGET POPULATION Inclusin Criteria Patients 1-21 years ld Patients with suspected spntaneus pneumthrax r prven spntaneus pneumthrax Exclusin Criteria Patients less than 1 years ld Patients lder than 21 years ld BACKGROUND DEFINITIONS This guideline is intended fr patients with primary spntaneus pneumthrax nly. If underlying lung disease is suspected, the pulmnary service shuld be cnsulted and ther treatment regimens shuld be cnsidered. Surgical versus nn-surgical treatment is cntrversial, with high rates f reccurrence. Page 3 f 9

4 INITIAL EVALUATION AND CLINICAL MANAGEMENT IN THE ED/UC Triage Assessment Vital signs (VS) Histry regarding presentatin Dcument histry f nset f chest pain r dyspnea Histry f underlying lung disease Histry f trauma Histry f huffing, smking, r breath hlding Histry f prir pneumthrax Clinical interventins Keep patient upright and NPO Apply xygen if hypxic Triage at least level 2 Mnitring Place in rm immediately fr clinical evaluatin VS per nursing prtcl Cardipulmnary mnitring Oxygen if patient is hypxic Fluids, Electrlytes, Nutritin NPO NS blus if patient is unstable (decreased unilateral breath sunds, hyptensive, tachycardic, hypxic) Initial Clinical Exam Evaluate airway, breathing, circulatin If the patient is unstable with clinical cncern fr pneumthrax, resuscitate as needed Administer 100% xygen 2 large bre IV catheters NPO IV fluid resuscitatin Using lcal anesthesia, place minimum size 8fr chest tube and/r needle decmpressin f chest if cncern fr tensin pneumthrax Admit t surgery service If the patient is stable, prceed t imaging (CXR) Upright PA If pneumthrax is identified, bjectively gauge the size Small pneumthrax (less than r equal t 1 cm f air between chest wall and lung): Chest tube is likely nt necessary. Place n xygen bserve in the ED with plan t D/C if imprved within 4 hurs. Mderate pneumthrax (1-2cm f air between chest wall and lung): Cnsider chest tube placement. Place n xygen and discuss with surgery service. Keep NPO and prepare fr mderate sedatin. Page 4 f 9

5 Large pneumthrax (greater than r equal t 2 cm f air between chest wall and lung): Patient will likely need a chest tube. Place n xygen and discuss with the surgery service. Keep NPO and prepare fr mderate sedatin. If cncerned fr underlying lung disease cnsider a pulmnary cnsult. Treatment in Stable Patient Wh Requires Chest Tube fr Primary Spntaneus Pneumthrax ED attending Discuss the need fr a chest tube with the surgery attending Verbal cnsent fr mderate sedatin Arrange and supervise the sedatin fllwing the Sedatin Guidelines Surgery attending Will supervise placement f the chest tube by the ED/Peds/Surgery resident Arrange fr admissin t surgery service Labratry Studies N empiric labs required Medicatins N empiric antibitics required Pain management Scheduled NSAIDs and narctics per ED discretin MANAGEMENT OF THE PATIENT WITHOUT A CHEST TUBE 2,3 Vital signs every 2 hurs with pain scre fr the first 8 hurs, then every 4 hurs if stable Pulse x and CR mnitring if the patient is rdered fr piid pain medicatin The list belw may be signs f deteriratin: Tachycardia Falling bld pressure Increasing pain Increasing dyspnea Use f 100% xygen (AKA nitrgen washut) is cntrversial and nt clearly shwn t decrease the pneumthrax If narctics are used, fllw bwel regimen t prevent cnstipatin and Valsalva maneuvers that can cmplicate pneumthrax Repeat upright PA CXR in hurs D/C criteria: Stable fr hurs and satisfactry pain cntrl (preferably withut narctics) PCP fllw up ensured Page 5 f 9

6 MANAGEMENT OF THE PATIENT WITH A CHEST TUBE Cnsideratin f Pulmnary cnsultatin Air leak shuld reslve within 3 days, but if nt, cnsider cnsulting pulmnary fr underlying lung disease If patient s histry indicates underlying lung disease then cnsult the pulmnary service Cnsideratin f VATS 4 Air leak persistent fr > 3 days after initial thracstmy tube management Recurrent episde Use f CT fr decisin making is prvider dependent. CT findings have nt been shwn t be predictive f recurrence and CT will have a significant false negative rate fr blebs 5. CT has nt been shwn t be helpful in prphylactic management f cntralateral findings. If perative management is chsen, there is mixed data as t ptimal apprach 6. Sme data supprt pleurdesis (mechanical r chemical) cmbined with blebectmy reduces pneumthrax recurrence rate. Chemical pleurdesis is generally expected t cause mre pain and have a lnger length f stay. Ketrlac des nt reduce the effectiveness f pleurdesis 7. DISCHARGE INSTRUCTIONS There is a high rate f pneumthrax reccurrence after VATS prcedure r chest tube drainage. Clse fllwup is recmmended. Air Travel and scuba diving is discuraged fr 48 hurs pst chest tube remval. Travel ver muntain passes with cautin due t lw barmetric pressure at high altitude. If narctics are required, cntinue the bwel regimen after discharge. Fllw-up Instructins Fllw-up with PCP and surgery clinic if VATS was perfrmed. Fllw-up with PCP within 1 week if discharged hme withut interventin. Fllw-up in pulmnary clinic if underlying lung disease is suspected. Page 6 f 9

7 References 1. Bintcliffe OJ, Hallifax RJ, Edey A, et al. Spntaneus pneumthrax: time t rethink management? Lancet Respir Med 2015;3: Seguier-Lipszyc E, Elizur A, Klin B, Vaiman M, Ltan G. Management f primary spntaneus pneumthrax in children. Clin Pediatr (Phila) 2011;50: Rbinsn PD, Cper P, Ranganathan SC. Evidence-based management f paediatric primary spntaneus pneumthrax. Paediatr Respir Rev 2009;10:110-7; quiz Lpez ME, Falln SC, Lee TC, Rdriguez JR, Brandt ML, Mazzitti MV. Management f the pediatric spntaneus pneumthrax: is primary surgery the treatment f chice? American jurnal f surgery 2014;208: Guimaraes CV, Dnnelly LF, Warner BW. CT findings fr blebs and bullae in children with spntaneus pneumthrax and cmparisn with findings in nrmal age-matched cntrls. Pediatric radilgy 2007;37: Bialas RC, Weiner TM, Phillips JD. Vide-assisted thracic surgery fr primary spntaneus pneumthrax in children: is there an ptimal technique? J Pediatr Surg 2008;43: Lizard RE, Langness S, Davenprt KP, et al. Ketrlac des nt reduce effectiveness f pleurdesis in pediatric patients with spntaneus pneumthrax. J Pediatr Surg Page 7 f 9

8 CLINICAL IMPROVEMENT TEAM MEMBERS Oren Kupfer, MD Pulmnary Medicine Paul Stillwell, MD Pulmnary Medicine Tara Neubrand, MD Emergency Medicine Jennifer Bruny, MD Pediatric Surgery Aimee Bernard, PhD Clinical Care Guideline Crdinatr Jesse Herrgtt, RN Clinical Effectiveness APPROVED BY Clinical Care Guidelines & Measures Review Cmmittee May 10, 2016 Medicatin Safety Cmmittee Nt Applicable Antimicrbial Stewardship Cmmittee Nt Applicable Pharmacy & Therapeutics Cmmittee Nt Applicable MANUAL/DEPARTMENT ORIGINATION DATE LAST DATE OF REVIEW OR REVISION Clinical Care Guidelines/Quality December 31, 2015 Nt Applicable APPROVED BY Lalit Bajaj, MD, MPH Medical Directr, Clinical Effectiveness REVIEW/REVISION SCHEDULE Scheduled fr full review n May 10, 2020 Clinical pathways are intended fr infrmatinal purpses nly. They are current at the date f publicatin and are reviewed n a regular basis t align with the best available evidence. Sme infrmatin and links may nt be available t external viewers. External viewers are encuraged t cnsult ther available surces if needed t cnfirm and supplement the cntent presented in the clinical pathways. Clinical pathways are nt intended t take the place f a physician s r ther health care prvider s advice, and is nt intended t diagnse, treat, cure r prevent any disease r ther medical cnditin. The infrmatin shuld nt be used in place f a visit, call, cnsultatin r advice f a physician r ther health care prvider. Furthermre, the infrmatin is prvided fr use slely at yur wn risk. CHCO accepts n liability fr the cntent, r fr the cnsequences f any actins taken n the basis f the infrmatin prvided. The infrmatin prvided t yu and the actins taken theref are prvided n an as is basis withut any warranty f any kind, express r implied, frm CHCO. CHCO declares n affiliatin, spnsrship, nr any partnerships with any listed rganizatin, r its respective directrs, fficers, emplyees, agents, cntractrs, affiliates, and representatives. Page 8 f 9

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