A 6-year-old girl with a nonproductive cough for 4 days and chest pain for 2 days was brought to the emergency department. According to the mother, the child had no fever or wheezing. She had no history of surgery, was not taking any medications, and had no contact with ill persons.
The child appeared well on examination, talked easily, and walked without difficulty. Her vital signs were stable. Oxygen saturation, measured with a pulse oximeter, was 98% on room air. The trachea was midline without deviation. Heart sounds were regular without murmur. Diminished breath sounds were heard on the left side. No wheezes or rhonchi were audible. Extremities were without edema.
Laurie Meng, PA-C, of Savoy, Ill, reports that the anteroposterior and lateral chest radiographs revealed an approximate 40% pneumothorax on the left.
Spontaneous pneumothorax is rare in children; most cases occur in adolescent boys with thin body habitus.1 As in most patients with spontaneous pneumothorax, this child had no lung disease or trauma.Children with cystic fibrosis or AIDS may be at increased risk for development or recurrence of pneumothorax secondary to infection. Neither disease was present in this patient.
Symptoms vary because of the degree of intrapleural pressure, rapidity of onset, age of the child, and the extent of preexisting respiratory compromise.Patients with primary or spontaneous pneumothorax (those without lung disease) may be asymptomatic or they may present with chest pain, cough,or dyspnea. Patients with secondary pneumothorax (from acute or chronic lung disease or trauma) may have pleuritic chest pain, dyspnea, tachypnea, cyanosis, and decreased breath sounds on the affected side.2
Treatment plans are based on the size of the pneumothorax, symptoms, and clinical presentation. In general, a small, simple pneumothorax can be managed conservatively with close observation with or without supplemental oxygen and repeated chest radiographs. A large, symptomatic pneumothorax may be managed with needle aspiration or chest tube insertion.
This patient was hospitalized for observation, and oxygen was administered through a nonrebreather mask at 15 L/min. Repeated chest radiographs showed slight improvement. Her clinical course was stable. After 3 days, she was discharged and scheduled for close follow-up with her pediatrician and additional chest radiographs.