The impact of a car crash, a bicycle hitting a tree or just a fall to the ground while holding one's breath — all mechanisms of injury that may involve direct force to the chest — can lead to lung compression from a child's ribs, inducing pneumothorax. Even an act as minor as a child grunting, which may increase thoracic pressure, can lead to lung collapse during trauma.
Why kids are at particular risk of pneumothorax
A number of factors put pediatric patients at particular risk of pulmonary contusions and subsequent pneumothorax, according to Christopher Moir, M.D., a pediatric and trauma surgeon at Mayo Clinic's campus in Rochester, Minnesota:
Childhood trauma incidence
The mere fact of being a child is a risk factor for pneumothorax, as there is a much higher incidence of general trauma throughout childhood. Data from the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control indicate nearly 6.8 million unintentional, nonfatal injuries occurred in U.S. children and adolescents ages 0 to 18 in 2017, while almost 12,000 died of such injuries.
Children are often pedestrians or traveling by bicycle. A child who is hit by a car is more likely to experience a direct hit to the chest than is a taller adult.
With the smaller height and weight of children, objects exert a greater force per area in a child than in a full-size adult. The force can indent a child's pliable ribs directly into the lung. Also because of a child's size, when a child is hit by an object — such as a vehicle hitting a child on a bike — the child is more likely to be thrown a greater distance than is someone full-grown. Both of these factors increase the risk of lung damage.
Characteristics of the chest wall
In pediatric patients, the chest wall is much softer than in an adult, and the ribs don't protect the chest as fully as with a full-grown person. This will cause more lung contusions in younger children. In older children, if a rib fractures, risk of pneumothorax increases, as noted in a 2011 issue of the Journal of Emergencies, Trauma, and Shock.
Teens have notably distinct risks of pneumothorax. This fact is particularly true for tall, thin, rapidly growing males, says Dr. Moir, due to a temporary lung weakness that can make them more susceptible to pneumothorax if they experience traumatic injury. In addition, teens engage in risk-taking behavior, which increases risk of sustaining pneumothorax.
"Teens are mobile, adventurous and not necessarily in tune with the rules of the road," says Dr. Moir. "Younger children like to play and can unwittingly run out between cars or get in bike accidents, but teens have learned those lessons. Instead, they begin to participate in riskier activities like rock climbing and motorized sports."
How to recognize pneumothorax in kids
Recognizing pediatric pneumothorax can be challenging, says Dr. Moir. He notes it is difficult to pinpoint early respiratory failure in a child, who may have deceptively satisfactory oxygen saturation. Thus, it's important to look for early signs of respiratory distress.
One distinctive indication of this condition for the provider is hearing unequal breath sounds. Rapid breathing using accessory muscles, appearance of air hunger and preferring to sit up to keep the airway open also are important signals of distress. If time allows, a quick, portable X-ray in the trauma bay can offer visual indication of a child's pneumothorax.
How to manage pediatric pneumothorax
Dr. Moir suggests some key principles for pneumothorax management in children:
Watch and wait
There are times when a pneumothorax does not warrant intervention and can be monitored rather than treated. A CT scan may identify a small pneumothorax not seen on chest X-ray. Unless the child is symptomatic or going to the operating room for a long procedure, these patients may not require a chest tube.
If a pneumothorax is more significant and the child is symptomatic, it must be managed emergently in the local hospital. Standard care involves chest tube insertion. If the patient is in extremis, perform a needle thoracostomy as a bridge to a chest tube.
For pediatric patients with pneumothorax, transfer occurs when other injuries are present, such as head trauma with the potential for neurosurgical intervention, or pediatric intensive care monitoring is warranted.
"Transfer for pneumothorax itself isn't advisable," says Dr. Moir. "A lot of times local trauma professionals have already treated the child and saved a life: This is what they train for and how a good trauma system works. The reason for transfer is ongoing care and other injuries."
With services provided at a pediatric trauma center, patients with pneumothoraxes may receive blood in the helicopter, and, if needed, will be treated at the center's hybrid suites that encompass resuscitative care, interventional radiology, neurosurgery and other necessary procedures, without the need to move the patient.
About treating pediatric patients
If your team is unaccustomed to treating pneumothorax in children, Dr. Moir notes that the initial trauma assessment and resuscitation of pediatric patients is exactly the same as in an adult. He also says that your group can trust in the drill, rehearsal and review of the subtle nuances in a pediatric patient conducted as part of the trauma program.
For more information
Richter T, et al. Ventilation in chest trauma. Journal of Emergencies, Trauma, and Shock. 2011:2; 251.
Fatal injury data. CDC Injury Prevention and Control.
Nonfatal injury data. CDC Injury Prevention and Control.