Management Patterns and Outcomes of Children With Traumatic Occult Pneumothorax

A traumatic occult pneumothorax (oPTX) is a pneumothorax that is not present on chest x-ray (CXR) but is seen on computed tomography (CT). There is no current standard of care for management of an oPTX in pediatric trauma patients. We aim to describe current clinical presentation, imaging, interventions, and management patterns in children with oPTX.

We conducted a single institution, retrospective review of children ≤18 presenting to a level 1 American College of Surgeons-verified Pediatric Trauma Center with a traumatic oPTX from 2010 to 2023. We defined oPTX as a pneumothorax present on CT scan, but not on CXR. We excluded patients who had imaging done at an outside hospital that was not read at our institution. Variables included demographics, vitals, clinical details on trauma including injury severity score, size of pneumothorax, imaging results, interventions, including follow-up imaging via repeat CXR or CT chest, and outcomes.

We identified 162 children with oPTX. Most were male (62.2%), White (76.5%), and presented with blunt trauma (96.4%). The median age was 10.7 y. Of these, 117 (72.2%) received follow-up imaging via CXR or chest CT during admission. Compared to those without follow-up imaging, patients who received follow-up imaging had significantly higher injury severity score (17.0 versus 11.0, P < 0.0001) were more likely to be mechanically ventilated on arrival (17.1% versus 0%, P = 0.0027) and were more frequently admitted to the intensive care unit (45.4% versus 8.9%, P < 0.0001). They were also more frequently documented as hypoxic (13.0% versus 0%, P = 0.0011), received more supplemental oxygen (53.7% versus 28.9%, P = 0.005), and had higher rates of central venous catheter placement (12.0% versus 0%, P = 0.015) and chest tube placement (7.7% versus 0%, P = 0.007). In contrast, patients without follow-up imaging were more likely to be transferred from an outside facility (68.9% versus 49.6%, P = 0.034) and had fewer pulmonary complications, including significantly lower rates of mechanical ventilation during admission (0% versus 25.0%, P = 0.0002). There were no significant differences in discharge location, surgery clinic follow-up, emergency department visits, or readmissions between groups. A total of 499 follow-up imaging studies were obtained, of which 202 (40.5%) were for screening. Almost 29 CXRs were needed prior to identification of a PTX requiring chest tube placement, with most screening CXRs (n = 195, 96.2%) determined to be unnecessary.

Pediatric trauma patients with oPTX more often received follow-up imaging if they had a higher injury score or pulmonary complications or were on mechanical ventilation. However, there was no difference in outcomes between the two groups, and most screening CXRs did not affect the patient's course. Patients with lower injury scores, no need for mechanical ventilation, and who are asymptomatic may be considered safe to observe without follow-up imaging.