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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Management of pediatric primary spontaneous pneumothorax &#40;PSP&#41; is based on adult literature and the best therapeutic algorithm for PSP is still debatable&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> The aim of this work was to review the approach to pediatric PSP in a tertiary care hospital&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Clinical charts of patients admitted with first episode of PSP at Hospital S&#227;o Jo&#227;o &#40;Porto&#44; Portugal&#41; between January 2006 and January 2012 were reviewed and analyzed for demographic&#44; diagnosis&#44; treatment and follow-up&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The management of PSP followed the institution protocol&#58; small &#40;&#60;20&#37;&#41; pneumothoraxes are treated with high output oxygen therapy&#59; moderate to large pneumothoraxes &#40;&#62;20&#8211;25&#37;&#41; are treated with chest tube drainage or needle aspiration&#46; Surgical indications are&#58; second ipsilateral pneumothorax&#59; first contralateral pneumothorax&#59; bilateral pneumothorax or persistent air leakage &#40;&#62;4 days&#41;&#46; All patients proposed for elective surgery had a computerized tomography scan &#40;CT&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Twenty-five patients with a first episode of PSP were included&#44; with a male predominance &#40;80&#37;&#41; as described in the literature&#46; Chest pain was the most frequent presentation &#40;&#62;80&#37;&#41; followed by dyspnea and cough&#46; Five patients had asthma&#44; three were active smokers and one had a family history of PSP&#46; With a follow-up range from one to six years&#44; there were seven recurrences&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The results of the therapeutic algorithm are summarized in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; Eight of the initial episodes and 1 recurrence were successfully treated with oxygen therapy&#59; success rate was 43&#37; for first episodes&#46; Chest tube was the next step and was used in 12 initial episodes with a success rate of 75&#37;&#59; however&#44; chest tubes failed in all recurrent episodes&#46; A total of 11 patients underwent thoracoscopy&#58; 5 during the first episode and 6 during recurrence&#46; Thoracoscopy proved to be successful in all cases&#44; with no recurrences&#46; In the presence of blebs&#44; mechanical pleurodesis with bleb resection was performed&#44; whereas in absence of blebs a mechanical pleurodesis was performed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The overall length of stay was longer for patients treated with thoracoscopy compared to patients treated with oxygen therapy or chest tube &#40;respectively 13&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;3&#44; 3&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2&#44; 6&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3 days&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; However&#44; patients were hospitalized with a mean of 8 days before surgery and if this is taken into account&#44; there is no significant difference between treatments&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In case of oxygen therapy failure&#44; symptomatic or large PSP&#44; American College of Chest Physicians favors chest tube&#44; while British Thoracic Society &#40;BTS&#41; prefers needle aspiration&#59; both have similar efficiency and recurrence rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;3</span></a> Robinson et al&#46; have recently reported the implementation of the BTS guidelines in Australia and New Zealand with a large multicenter series&#44; addressing the efficacy of needle aspiration&#46; Although they do not separate the recurrent from the initial episodes of PSP&#44; they report an identical success rate &#40;46&#37;&#41; for expectant treatment independently of oxygen use&#46; As in our study&#44; when intervention was needed&#44; chest tube was still the first-line &#40;used in 79&#37;&#41;&#59; needle aspiration was used in only 21&#37; of patients&#44; with a success rate of 52&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> In recurrent episodes&#44; the efficiency falls after non-operative treatment&#44; with described success rates as low as 52&#37; in the second episode and 15&#37; in the third&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Thoracoscopy may be more aggressive&#44; but it has the lowest reported recurrence rate &#40;5&#8211;75&#37;&#41;&#59; in our study&#44; thoracoscopy was always successful and there were no recurrences&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4&#44;6&#44;7</span></a> In adult population&#44; thoracoscopic surgery is being proposed as an alternative to chest tube even in first episodes&#44; with lower recurrence rate and shorter hospital stay&#46; However&#44; randomized studies in pediatric population still advocate conservative management for initial PSP episodes&#44; since several patients will never need surgical intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Finally&#44; the presence of blebs in the CT scan has been suggested as an independent risk factor for recurrence&#44; but its usefulness remains controversial&#46; Some studies indicate that blebs may not predict recurrence and CT scan findings should not be used as a basis for prophylactic surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;6&#44;8</span></a> In our study&#44; more than a half of the patients had no blebs in the CT scan &#40;58&#37;&#41; but blebs were associated with higher recurrence rate &#40;63&#37; versus 18&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;048&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The best treatment for first PSP in pediatrics is probably conservative &#40;oxygen therapy&#44; needle aspiration or chest tube drainage&#41;&#46; Nevertheless&#44; thoracoscopy is efficient and seems to be the best option in refractory or recurrent PSP&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Letter to the Editor
Management of pediatric primary spontaneous pneumothorax in a tertiary hospital
R. Lamas-Pinheiroa,
Corresponding author
rubenlms@hotmail.com

Corresponding author.
, J. Branco-Salvadora, J. Jardimb, C. Ferrazb, T. Nunesb, L.G. Vazb, I. Azevedob, T. Henriques-Coelhoa
a Department of Pediatric Surgery, Hospital São João, Faculty of Medicine, Porto, Portugal
b Department of Pediatric Pulmonology, Hospital São João, Faculty of Medicine, Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Management of pediatric primary spontaneous pneumothorax &#40;PSP&#41; is based on adult literature and the best therapeutic algorithm for PSP is still debatable&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> The aim of this work was to review the approach to pediatric PSP in a tertiary care hospital&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Clinical charts of patients admitted with first episode of PSP at Hospital S&#227;o Jo&#227;o &#40;Porto&#44; Portugal&#41; between January 2006 and January 2012 were reviewed and analyzed for demographic&#44; diagnosis&#44; treatment and follow-up&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The management of PSP followed the institution protocol&#58; small &#40;&#60;20&#37;&#41; pneumothoraxes are treated with high output oxygen therapy&#59; moderate to large pneumothoraxes &#40;&#62;20&#8211;25&#37;&#41; are treated with chest tube drainage or needle aspiration&#46; Surgical indications are&#58; second ipsilateral pneumothorax&#59; first contralateral pneumothorax&#59; bilateral pneumothorax or persistent air leakage &#40;&#62;4 days&#41;&#46; All patients proposed for elective surgery had a computerized tomography scan &#40;CT&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Twenty-five patients with a first episode of PSP were included&#44; with a male predominance &#40;80&#37;&#41; as described in the literature&#46; Chest pain was the most frequent presentation &#40;&#62;80&#37;&#41; followed by dyspnea and cough&#46; Five patients had asthma&#44; three were active smokers and one had a family history of PSP&#46; With a follow-up range from one to six years&#44; there were seven recurrences&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The results of the therapeutic algorithm are summarized in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; Eight of the initial episodes and 1 recurrence were successfully treated with oxygen therapy&#59; success rate was 43&#37; for first episodes&#46; Chest tube was the next step and was used in 12 initial episodes with a success rate of 75&#37;&#59; however&#44; chest tubes failed in all recurrent episodes&#46; A total of 11 patients underwent thoracoscopy&#58; 5 during the first episode and 6 during recurrence&#46; Thoracoscopy proved to be successful in all cases&#44; with no recurrences&#46; In the presence of blebs&#44; mechanical pleurodesis with bleb resection was performed&#44; whereas in absence of blebs a mechanical pleurodesis was performed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The overall length of stay was longer for patients treated with thoracoscopy compared to patients treated with oxygen therapy or chest tube &#40;respectively 13&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;3&#44; 3&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2&#44; 6&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3 days&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; However&#44; patients were hospitalized with a mean of 8 days before surgery and if this is taken into account&#44; there is no significant difference between treatments&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In case of oxygen therapy failure&#44; symptomatic or large PSP&#44; American College of Chest Physicians favors chest tube&#44; while British Thoracic Society &#40;BTS&#41; prefers needle aspiration&#59; both have similar efficiency and recurrence rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;3</span></a> Robinson et al&#46; have recently reported the implementation of the BTS guidelines in Australia and New Zealand with a large multicenter series&#44; addressing the efficacy of needle aspiration&#46; Although they do not separate the recurrent from the initial episodes of PSP&#44; they report an identical success rate &#40;46&#37;&#41; for expectant treatment independently of oxygen use&#46; As in our study&#44; when intervention was needed&#44; chest tube was still the first-line &#40;used in 79&#37;&#41;&#59; needle aspiration was used in only 21&#37; of patients&#44; with a success rate of 52&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> In recurrent episodes&#44; the efficiency falls after non-operative treatment&#44; with described success rates as low as 52&#37; in the second episode and 15&#37; in the third&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Thoracoscopy may be more aggressive&#44; but it has the lowest reported recurrence rate &#40;5&#8211;75&#37;&#41;&#59; in our study&#44; thoracoscopy was always successful and there were no recurrences&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4&#44;6&#44;7</span></a> In adult population&#44; thoracoscopic surgery is being proposed as an alternative to chest tube even in first episodes&#44; with lower recurrence rate and shorter hospital stay&#46; However&#44; randomized studies in pediatric population still advocate conservative management for initial PSP episodes&#44; since several patients will never need surgical intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Finally&#44; the presence of blebs in the CT scan has been suggested as an independent risk factor for recurrence&#44; but its usefulness remains controversial&#46; Some studies indicate that blebs may not predict recurrence and CT scan findings should not be used as a basis for prophylactic surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;6&#44;8</span></a> In our study&#44; more than a half of the patients had no blebs in the CT scan &#40;58&#37;&#41; but blebs were associated with higher recurrence rate &#40;63&#37; versus 18&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;048&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The best treatment for first PSP in pediatrics is probably conservative &#40;oxygen therapy&#44; needle aspiration or chest tube drainage&#41;&#46; Nevertheless&#44; thoracoscopy is efficient and seems to be the best option in refractory or recurrent PSP&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Pulmonology

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