Written By Ketan Patel
Spoon Feed
In pediatric patients with a traumatic pneumothorax (tPTX), only Collins size greater than 12.5% on chest x-ray (CXR) independently predicted failure of observation versus tube thoracostomy (TT) placement in management.
Tube or no tube? Let the x-ray do the talking
There are no definitive guidelines on the management of tPTX in pediatric patients, and if incorrectly managed, progression can be rapid and consequences can be severe. Unlike adults, overreliance on CT scans and reducing radiation exposure is paramount when making decisions for TT placement.
This retrospective study examined whether the size of traumatic pneumothorax (tPTX) on initial chest x-ray predicts failed observation (i.e., requiring delayed tube thoracostomy [TT]) in pediatric patients. Conducted at a single Level 1 pediatric trauma center (2010–2023), 313 children with 358 tPTX episodes were analyzed. Among observed cases, 13.5% failed observation. A Collins method tPTX size ≥12.5% was independently associated with failure (aOR 6.31, 95%CI 2.57–15.47), while ventilation, hypotension, and hemopneumothorax were not. Limitations include retrospective design and single-center scope. CXR-based size assessment may guide TT decisions in children. Limitations of the study are inherent due to its retrospective, single-center nature, with limited generalizability. In addition, several other factors may not be well elucidated in reasoning for TT placement given a small percentage of traumatic hemothorax patients in comparison to tPTX.
How does this change my practice?
The decision to place a TT is not a simple one, especially in the pediatric population. For me, this study serves as a springboard for potential future guidelines and prospective studies using the 12.5% cutoff proposed. Until then, a holistic and cautious approach considering size, clinical picture, and expertise of the treating providers will continue to drive decisions about TT placement in these patients.
Source
Size of traumatic pneumothorax on initial chest x-ray is independently associated with failed observation in children. J Trauma Acute Care Surg. 2025 Jul 3. doi: 10.1097/TA.0000000000004638. Epub ahead of print. PMID: 40604364
