Received: 24 March 2023 | Accepted: 10 September 2023

DOI: 10.1002/ppul.26703

ORIGINAL ARTICLE

Conservative and operative management of spontaneous

pneumothorax in children and adolescents: Are we abusing
of CT?

Angelo Zarfati MD | Valerio Pardi MD | Simone Frediani MD, PhD |

Ivan Pietro Aloi MD | Antonella Accinni MD | Arianna Bertocchini MD |
Silvia Madafferi MD | Alessandro Inserra MD

General and Thoracic Pediatric Surgery Unit,

Bambino Gesù Children's Hospital, IRCCS,
Rome, Italy
Correspondence
Simone Frediani, MD, PhD, General and
Thoracic Pediatric Surgery Unit, Bambino
Gesù Children's Hospital, IRCCS, Rome, Italy.
Email: simone.frediani@opbg.net
Abstract
Background: No age‐specific pediatric guidelines exist for the management of
spontaneous pneumothorax (SP) in children and adolescents. Treatment remains
heterogeneous and center dependent. The role of computed tomography (CT) has
yet to be defined.
Aims: Review the management of SP in children and adolescents, with emphasis on

Funding information
conservative management and role of CT.
None Methods: Retrospective analysis of 61 consecutive patients with SP at single tertiary
center. Clinical, radiological, surgical data, follow‐up, and outcomes were revised.
Results: First‐line management was conservative for 32 (53%) patients and operative
for 29 (47%). Asymptomatic/paucisymptomatic patients managed conservatively
experienced less first‐line treatment failure. Furthermore, the patients needing at least
a chest drain or surgery during the follow‐up were significantly lower in the
conservative group. Conservative and operative patients showed no significant
differences regarding ipsilateral recurrences or contralateral occurrences. Of the 61
overall CTs performed, 14 (23%) had an impact on management. Forty‐three (70%)
patients had at least a CT, in 22 (51%) the CT was positive for blebs. For 10 of these
patients (45%) the presence of blebs had an impact on management. Patients with and
without blebs showed no differences regarding ipsilateral recurrence, contralateral
occurrences, or the need for at least a chest drain or surgery during the follow‐up.
Conclusions: First‐line conservative management had a significantly shorter hospitaliza-
tion and better outcome, with a similar incidence of recurrences. The presence of blebs at
CT does not predict the risk of recurrence. The CT scan should be reserved for a small
number of selected patients who have post‐VATS refractory or recurrent pneumothorax.

KEYWORDS
children, computed tomography, drainage, pneumothorax, VATS

Abbreviations: CT, computed tomography; SP, spontaneous pneumothorax; VATS, video assisted thoracic surgery.

This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any
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© 2023 The Authors. Pediatric Pulmonology published by Wiley Periodicals LLC.

Pediatric Pulmonology. 2023;1–7. wileyonlinelibrary.com/journal/ppul | 1


2 |
1 | INTRODUCTION
Spontaneous pneumothorax (SP) is a relatively rare condition in
pediatric population.1 Tall, thin, male adolescents are more likely to
develop SP.1–3 Today, no age‐specific pediatric guidelines exist for
the management of children and adolescents with SP, and therapeu-
tic approaches are drawn from adult literature. There are a number of
adult recommendations, however there are still big discrepancies
between them in terms of diagnosis and indications.4–7 Management
in pediatric patients remains heterogeneous and center dependent.4,8
The use of CT remains controversial. CT is not routinely
performed in pediatric SP, and its role is not yet clear. While it has
been reported that the finding of blebs/bullous lesions on CT is an
9
indication for surgery, some authors have reported that these are
not predictive of outcome or recurrence.8,10,11 However, some
authors reserve a role for CT in selected cases.10,12 Others reported
even a useless overuse by clinicians.10
The aim of the present study was to analyze the management of
spontaneous pneumothorax in children and adolescents, with
particular emphasis on the role of conservative management in
asymptomatic/paucisymptomatic patients. Additionally, we wanted
to review the role of the CT versus video‐assisted thoracic surgery
(VATS), focusing on their impact and value on outcomes and
recurrence.
2 | MATERIALS AND METHODS
A retrospective review of consecutive patients with SP at single
tertiary center (Pediatric Surgery Unit, Bambino Gesù Pediatric
Hospital, IRCCS) between January 2010 and January 2022 was
undertaken. Clinical, radiological, and surgical data, follow‐up and
outcomes were revised. Exclusion criteria included incomplete data,
being lost to follow‐up and older than 18 at the time of diagnosis. The
number of cases managed at our Institution during the study period
determined the sample size. Locally and nationally referred patients
composed the study population. There was no randomization, and
management was determined by the surgeon's discretion.
Patients were defined as asymptomatic in the absence of
symptoms, paucisymptomatic in case of mild chest pain, cough or
mild dyspnea, and highly symptomatic in the case of severe pain
or dyspnea. The first line management may be conservative or
operative. At the authors' institution conservative management
consisted in hospitalization for clinical and vital signs monitoring,
painkillers, and oxygen therapy. Instead, at our institution, the
operative management included chest tube placement and VATS.
The chest tube placement, except emergent life threating
situations, was ed in the operative room under general anesthe-
sia. Instead, the thoracoscopic approach consisted in an
exploration of pleural space and lung parenchyma. When
bullae/blebs were found at exploration, the lesions were
resected. Furthermore, the procedure may consist in a mechani-
cal or chemical pleurodesis.
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ZARFATI ET AL.
After the first chest X‐ray performed in the emergency room the
timing of a repeat X‐ray depended on the clinical status. In case of
favorable evolution, the X‐ray was performed at symptom remission
to allow the discharge. Otherwise, the X‐ray was repeated in any
moment of degradation. The failure of the first‐line management was
defined as the need for surgery for a SP refractory or persistent to
the treatment. In the authors' institution postoperative management
of the chest tube and discharge criteria were the following: in the
absence of an air leak, the chest tube is closed. A chest X‐ray is
performed to rule out any persistent pneumothorax after 12–24 h of
closure. The tube is removed if there is no or very little persistent
pneumothorax. After the removal of the chest tube, the patients are
released.
We considered that a CT with an “impact on the management”
when it changed the patients care (e.g., indication to drain placement,
indication to surgery, etc). We defined a CT positive for blebs with an
“impact on the management” when it changed the patients care (e.g.,
indication to surgery, etc).
Categorical variables were reported as absolute and relative
frequencies (%). Continuous variables were reported as median and
range. As necessary, categorical variables were compared between
groups using the Fisher exact test or the χ2 test. Differences between
groups for continuous variables were determined using a non-
parametric test, Mann–Whitney U test. All p values were two‐sided,
and a p < .05 was considered significant.
3 | RESULTS
The overview of the study is presented in Figure 1. Baseline and
general characteristics are detailed in Table 1. Sixty‐one patients
were identified with a median age of 14.2 years (range 2.3–17.9).
Fourteen patients (22%) were female. Eight (13%) had Marfan
syndrome, and seven (11%) had a history of asthma. At presentation,
53 (87%) were paucisymptomatic, seven (11%) were highly sympto-
matic and one (2%) was asymptomatic. The pneumothorax was on
the left side in 35 (57%) of the cases, on the right side in 25 (41%),
and bilateral in 1 (2%).
First‐line management was conservative for 32 (53%) and
operative for 29, and their comparison is presented in Table 2. The
operative management was drainage for 24 and surgery for 5. In the
surgically treated subgroup, apical blebs were discovered in three of
the five paintings after a VATS exploration, which was performed on
all of them. In the remaining two the exploration was negative. One
of these patients underwent pleurodesis through scarification. In
every case, a postoperative chest tube was inserted for a median of 9
days (range: 3–15 days). Overall, the median hospital stay was 6 days
(range 0–45). The median hospital stay was significantly shorter in
the conservative group (4 days [range 0–33] vs. 8 [7–45], p < .00001).
Overall, 10 (16%) patients needed further surgery for the treatment
of first‐line management failure. All 10 patient received a VATS
exploration, and 8 of them had their apical blebs removed. In such
subsets, two individuals underwent an additional pleurodesis (one
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ZARFATI ET AL. | 3

FIGURE 1 Overview of the study.

TABLE 1 Baseline and general data.

Patients 61

Median age at first episode (range) 14.2 (2.3–17.9)

Females 22% (14)

Marfan 13% (8)

Asthma 11% (7)

Presentation Asymptomatic 2% (1)

Paucisymptomatic 87% (53)

Highly symptomatic 11% (7)

Side Left 57% (35)

Right 41% (25)

Bilateral 2% (1)

First‐line management Conservative 53% (32)

Operative Overall 47% (29)

Drainage 24

Surgery 5

Median age at follow‐up end (range) 17.2 (5.5–27)

Median years of follow‐up (range) 1.2 (0.1–12)

TABLE 2 Comparison of first‐line management outcomes and follow‐up.

Total (n = 61) Conservative (n = 32) Operative (n = 29) p Value

Median days of hospitalization at first episode (range) 6 (0–45) 4 (0–33) 8 (3–45) <.00001

First‐line treatment failure needing further surgery 16% (10) 6% (2) 27% (8) .037

≥1 ipsilateral recurrence 39% (24) 31% (10) 48% (14) .199

≥1 contralateral occurrence 14% (9) 9% (3) 20% (6) .287

≥1 surgery or chest drain during the follow‐up 36% (22) 21% (7) 51% (15) .018
 10990496, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ppul.26703 by Cochrane Romania, Wiley Online Library on [23/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4 | ZARFATI ET AL.

TABLE 3 Comparison of first‐line management outcomes and follow‐up depending on the type of operative management.

Total (n = 29) Drainage (n = 24) Surgery (n = 5) p Value

Median days of chest tube (range) 8 (3–45) 8 (3–45) 9 (3–15) .756

First‐line treatment failure needing further surgery 27% (8) 33% (8) 0% (0) .283

≥1 ipsilateral recurrence 48% (14) 54% (13) 20% (1) .329

≥1 contralateral occurrence 20% (6) 25% (6) 0% (0) .552

≥1 surgery or chest drain during the follow‐up 51% (15) 54% (13) 40% (2) .650

T A B L E 4 Role of CT for management and follow‐up of SP in Regarding the role of the CT (Table 4), 43 (70%) patients had at
children and adolescents. least a CT at diagnosis, during management, or at follow‐up, while 12

Patients with ≥1 CT
Patients with ≥2 CT
Overall CTs
CT timing
70% (43) (19%) had at least two CTs. Despite the complete absence of
symptoms, the CT was repeated in 10 of the 12 patients to rule out
19% (12)
the presence of blebs during follow‐up visits after discharge. For the
61 other two, a repeat CT was done at the first episode due to a
I episode 22% (14) persistent pneumothorax. Overall, 61 CTs were performed. Fourteen

Recurrence 13% (8) CTs (23%) had an impact on management. Regarding the timing, 14
(23%) were performed at the first episode, 8 (13%) at recurrence and
Follow‐up 63% (39)
39 (63%) during the follow‐up.
CT with an impact on management 23% (14) Of the 43 patients with at least one CT, 22 (51%) had at least one
Patients with ≥1 CT with an impact on management 54% (33) CT scan that was positive for blebs (Table 5). In 10 of these patients

Patients with ≥1 CT with Blebs
Patients with ≥1 CT with blebs with an impact on
management
Abbreviations: CT, computed tomography; SP, spontaneous
pneumothorax.
51% (22/43) (45%) the presence of blebs on CT had an impact on management.
However, patients with and without blebs at CT showed no
45% (10/22)
differences regarding ipsilateral recurrence (59% [13], vs. 33% [7],
p = .129), contralateral occurrences (13% [3], vs. 28% [6], p = .280), or
the need for at least a chest drain or surgery during the follow‐up
(54% [12], vs. 28% [6], p = .124).

talcage, one scarification). The remaining two had a negative

exploration. In every case, a postoperative chest tube was inserted
for a median of 8 days (range: 4–16 days). This failure was
significantly lower in the conservative group (6% [2/32] vs. 27%
[8/29], p = .037). Patients were followed for a median of 1.2 years
(range 0.1–12) and until a median age of 17.2 years (range 5.5–27).
During the follow‐up, 24 patients (39%) experienced ipsilateral
recurrence and nine (14%) had contralateral occurrences. Conserva-
tive and operative groups showed no statistically significant differ-
ences regarding ipsilateral recurrence (31% [10], vs. 48% (14),
p = .199) or contralateral occurrences (9% [3] vs. 20% [6], p = .287).
However, significantly fewer conservatively managed patients
needed at least a chest drain or surgery during the follow‐up (21%
[7] vs. 51% [15], p = .018).
The comparison of the first line operatively managed patients
is shown in Table 3. Patients treated with drainage and surgery
showed no statistically significant differences regarding days of
chest tube (8 [3–45] vs. 9 [3–15] p = .756), first‐line treatment
failure needing further surgery (33% [8] vs. 0% [0], p = .283),
ipsilateral recurrence (54% [13] vs. 20% [1], p = .329), contra-
lateral occurrences (25% [6] vs. 0% [0], p = .552), and the need for
at least a chest drain or surgery during the follow‐up (54% [13]
vs. 40% [2], p = .650).
4 | D IS CU SS IO N
In our experience, patients who were managed conservatively at the
first episode had significantly shorter hospitalizations and experi-
enced fewer treatment failures requiring surgery during the same
stay. Furthermore, these patients showed no statistically significant
differences during the follow‐up for ipsilateral recurrence and
contralateral occurrence. However, the patients needing at least
one surgery or chest drain during the follow‐up were significantly
fewer in the conservative group. The first systematic review and
meta‐analysis of pediatric spontaneous pneumothorax management
was recently published by Miscia et al.8
These authors concluded that first‐line surgery reduced the risk
of recurrence without increasing the hospital stay. Instead in the
present study, we found that first‐line operative management was
associated with an increased hospitalization length without decreas-
ing the risk of recurrence. This may be explicated by a possible
selection bias of our methodology. Due to the lack of randomization
or prospective design, the most severe cases were more likely be
treated operatively. So, we could have selected the patients who
were at higher risk of treatment failure, increased hospital stay
and recurrence.

ZARFATI ET AL.
TABLE 5 Comparison of outcomes and follow‐up of patients with blebs at CT and patients with a negative CT.
Patients with ≥1 CT (n = 43)
≥1 ipsilateral recurrence 46% (20)
≥1 contralateral occurrence 20% (9)
≥1 surgery or chest drain during the follow‐up 41% (18)
Abbreviation: CT, computed tomography.
In a recently published mixed adolescents‐adults randomized
13
control trial, Brown and colleagues reported interesting findings.
The study has been conducted in a mixed adolescent‐adult
population (14–50 years), with a first‐known, unilateral, moderate‐
to‐large primary spontaneous pneumothorax. The outcomes of
conservative management are really promising in this population.
However, the trial does not seem to be adequate for a pediatric
tertiary center for some methodological reasons. Pediatric studies, as
the present one, include a population quite different from the trial
(1–18 years, rather 14–50 years). Furthermore, the main criteria for
patient selection in this trial was the size. However, the size has been
calculated with the Collins and colleagues formula.14 Since its first
description in 1995, the clinical everyday use of this formula is
extremely limited and, to the authors best knowledge, the formula
has never been validated for a use in pediatric patients. Therefore,
any conclusion regarding the impact of the size on the outcomes on
pediatric cases may be misleading. Anyway, this trial has several
interesting and promising outcomes that need to be validation in a
pediatric setting. A similar trial should be conducted in pediatric
patients. This study may helpful to clarify many ambiguous aspects of
the management of the spontaneous pneumothorax in this setting, as
size definition (e.g., large pneumothorax), best first‐management (e.g.,
role of conservative management), role of CT, risk factors for
persistence or recurrence, and so forth.
One of the aims of the present study was to perform a critical
review the role of the CT, focusing on its impact and value on
outcomes and recurrence. We considered that a CT with had an
“impact on the management” when it changed the patients care (e.g.,
indication to drain placement, indication to surgery, etc). The
objective was to try to understand the number of avoidable CTs
(and radiations to pediatric patients) we performed. As quite evident
for the reader, it appears that CT was not helpful in most cases and
may lead to unnecessary interventions and radiation exposure.
Hoverer, the CT scan should be reserved for a small number of
patients with complex scenarios, as post‐VATS refractory or
recurrent pneumothorax.
Furthermore with the same logic, we defined a CT positive for
blebs with had an “impact on the management” when it changed the
patients care (e.g., indication to surgery, etc). The aim as always to
define the role of this finding on the patient's care. Of the patients
with at least one CT, 51% had at least one CT scan that was positive
for blebs. In 45% of these patients, the presence of blebs on CT had
an impact on management. From our limited experience, is still
unclear if blebs or bullae seen on CT or on VATS should lead to
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| 5
≥1 CT with Blebs (n = 22) No blebs (n = 21) p Value
59% (13) 33% (7) .129
13% (3) 28% (6) .280
54% (12) 28% (6) .124
surgical intervention. However, patients with and without blebs at CT
showed no differences regarding ipsilateral recurrence, contralateral
occurrences, or the need for at least a chest drain or surgery during
the follow‐up. Therefore, from this limited retrospective experience,
the presence of blebs does not seem to have a major impact of the
outcomes of SP patients.
In the present series, 70% of patients received at least one CT.
However, of all the 61 CTs performed only 14 (23%) had an impact
on the patient's management. Indeed, 77% of the CT performed
could have been avoided. Moreover, even in the 22 (51%) patients
with blebs at CT, only 45% of these had an impact on management.
Finally, the blebs and no blebs groups showed no statistically
significant difference during the follow‐up for ipsilateral recurrence,
contralateral occurrence or the need for surgery or drainage. In the
aforementioned paper Miscia and colleagues concluded that the
presence of blebs does not indicate a higher risk of recurrence.8 In
this sense, our experience is consistent with the available literature.
The analysis of our experience showed no difference of
outcomes between the two types of operative treatment considered,
VATS and drain. Therefore, these findings let us sometimes
reconsider our operative approach to highly symptomatic patients,
conservative management failure, persistent, or recurrent pneumo-
thorax. In our institution, in this selected group of complicate cases,
sometimes we may favor VATS over drainage‐only when there is an
indication for operative treatment. Therefore, given that both the
procedures require general anesthesia, we believe that in selected
cases the thoracoscopic exploration adds valuable diagnostic
information regarding the presence of blebs or associated anomalies.
Furthermore, after exploration the surgeon has three possibilities:
perform blebs resection, perform a pleurodesis, or leave only a chest
tube. The present series represent a clear and critical review of more
than a decade of experience of our large volume pediatric tertiary
center. This study consists in a report a period of stable and
homogeneous management. When we realized that some of our
practices may be improved we performed this critical analysis to
ameliorate the patient's care. Therefore, from our findings and the
recent literature we developed a protocol for the management of SP
in children and adolescents.7,8,11,12 (Figure 2). Our proposal had three
purposes: to redefine the role of conservative treatment, VATS and
CT, support the need for age‐specific management, and promote
debate between experts from tertiary centers. At presentation the
management should be guided by clinical status and symptoms.
Asymptomatic and pauci‐symptomatic patients at first episode
should be admitted to the hospital and treated conservatively with

6 |
FIGURE 2 The Bambino Gesù children's hospital protocol for management of spontaneous pneumothorax in children and adolescents.
oxygen. In cases of favorable evolution, with resolution or decrease
of the pneumothorax, the patient should be discharged with a clinical
and radiological check in 7–10 days. In the event of symptoms or if
the pneumothorax persists or worsens, the patients should have a
thoracoscopic exploration. In case of recurrence, patients should be
hospitalized and treated with oxygen therapy and VATS. Additionally,
during their hospital stay, these patients should have a multi-
disciplinary examination for comorbidities, which at our institution
includes a genetic, cardiologic, and ophthalmologic work‐up. Instead,
patients highly symptomatic at presentation should be hospitalized
and treated with oxygen and VATS. A chest drain should be
immediately placed in case of suspect of tensive pneumothorax.
Every time a VATS is performed the pleural space should be carefully
explored. In cases of blebs, a bullectomy should be performed.
Otherwise, a talcage should be considered in the absence of obvious
blebs. In any case, a chest drain should be placed. In cases of
postoperative persistence of pneumothorax or postoperative ipsi-
lateral recurrence, a chest CT should be considered to assess any
anatomical (residual blebs, etc.) or pathological (associated anomalies,
etc.) etiology before the repeat of a VATS exploration. The targeted
use of CT is perfectly in accordance with the current culture of
radioprotection, favoring the thoracoscopic approach the radiological
exposure is reduced and the therapeutic process is accelerated, also
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ZARFATI ET AL.
reducing the risks and stress of a longer hospital stay for the
patient.13,14
We recognize the limitations of the present experience. The first
is the retrospective nature and the limited monocentric sample of the
series. Additionally, this study lacks randomization and a prospective
design because of the methodology. Prospective and multicenter
studies are needed to generalize our findings.
In Conclusion, first‐line conservative management had a signifi-
cantly shorter hospitalization and experienced less treatment failure
requiring surgery, with a similar incidence of recurrences. The
presence of blebs at CT does not predict the risk of recurrence.
The CT scan should be reserved for a small number of patients who
have post‐VATS refractory or recurrent pneumothorax.
A UT H O R C O N T R I B U TI O NS
Angelo Zarfati: Conceptualization; investigation; funding acquisition;
writing–original draft; methodology; validation; visualization; writing—
review & editing; software; formal analysis; project administration;
data curation; supervision; resources. Valerio Pardi: Data curation;
supervision; resources; project administration; formal analysis; soft-
ware; methodology; validation; visualization; writing—review & editing;
conceptualization; investigation; funding acquisition; writing—original
draft. Simone Frediani: Conceptualization; investigation; funding

ZARFATI ET AL.
acquisition; writing—original draft; methodology; validation; visualiza-
tion; writing—review & editing; software; formal analysis; project
administration; data curation; supervision; resources. Ivan Pietro Aloi:
Data curation; supervision; resources; software; formal analysis; project
administration; methodology; validation; visualization; writing—review &
editing; conceptualization; investigation; funding acquisition; writing—
original draft. Antonella Accinni: Conceptualization; methodology;
software; data curation; supervision; resources; formal analysis; project
administration; validation; visualization; writing—review & editing;
investigation; funding acquisition; writing—original draft. Arianna
Bertocchini: Conceptualization; investigation; funding acquisition;
writing—original draft; methodology; validation; visualization; writing—
review & editing; software; formal analysis; project administration; data
curation; supervision; resources. Silvia Madafferi: Conceptualization;
investigation; funding acquisition; writing—original draft; methodology;
validation; visualization; writing—review & editing; software; formal
analysis; project administration; data curation; supervision; resources.
Alessandro Inserra: Data curation; supervision; resources; software;
formal analysis; project administration; methodology; validation; visual-
ization; writing—review & editing; conceptualization; investigation;
funding acquisition; writing—original draft.
A C KN O W L E D G M E N T
Open access funding provided by BIBLIOSAN.
CO NFL I CT OF INTERES T S T ATEME NT
The authors have no financial relationships or conflicts of interest to
disclose. The present study received authorization for publication
from the scientific board of the authors' institution.
D A TA A V A I L A B I L I T Y S T A T E M E N T
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
ORCID
Simone Frediani http://orcid.org/0000-0003-4629-8132
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How to cite this article: Zarfati A, Pardi V, Frediani S,
et al. Conservative and operative management of
Spontaneous Pneumothorax in children and adolescents:
are we abusing of CT? Pediatr Pulmonol. 2023;1‐7.
doi:10.1002/ppul.26703