Traumatic pneumothorax and haemothorax are the most frequent paediatric indications for tube thoracostomy. Pneumothorax is a serious sequela of major chest trauma in children and may occur as a result of blunt injury without rib fractures or chest penetration. Sometimes, spontaneous pneumothorax occurs without trauma, from rapid increase in intraluminal pressure, especially with patients who have pre-existing bronchopulmonary disease. Air or fluid in the pleural space can cause significant impediments to oxygenation/ventilation and drastically reduce cardiac output, usually when the haemothorax is large or the pneumothorax is under tension. Tension pneumothorax and large haemothorax are potentially lethal emergencies that require immediate chest decompression. Rarely, large pleural fluid collections from non-traumatic aetiologies, such as empyemas, that are causing respiratory distress, require tube thoracostomy for drainage.
The typical clinical presentation for tension pneumothorax and/or large haemothorax is the child who experiences a penetrating injury to the chest wall or back. A sucking chest wound may be present. Sometimes, these conditions result from penetrations below the nipple line or tip of the scapula that may also involve penetration into the abdomen, or from remote penetrations with gunshots that traverse multiple anatomic regions. Less frequently, blunt trauma is the mechanism. The classic adult clinical findings of unilateral decreased air movement and trachea shift are rarely present in children. More commonly, the clinical signs are tachypnoea, oxygen desaturation, retractions, flaring, grunting and shock.
Tube thoracostomy is the insertion of an intrapleural tube to evacuate air and/or fluid from the pleural space. The procedure is a time-honoured evacuation technique for all age patients, and it may be life saving. The technique is effective for removal of most pleural air or fluid collections and has a good safety record in children. The main differences in the procedure between adults and children are the need for more meticulous patient preparation and smaller catheters in children. Sometimes, detection of pleural air or fluid is more difficult in children, requiring computerised tomography (CT) imaging to localise and quantify.
In the setting of tension pneumothorax, needle thoracostomy (Chapter 23.7) may precede tube thoracostomy, but tube thoracostomy must always follow needle thoracostomy. Stable, small pneumothoraces not under tension (e.g. <20%), are usually managed with observation alone, without a chest tube. There is an increasing tendency to manage even moderate sized pneumothoraces without tension with observation only. Massive haemothorax occurs when a large vascular structure under systemic pressure bleeds into the pleural space. This is usually the internal mammary artery or an intercostal artery. In this setting, tube thoracostomy is the only treatment likely to salvage the child. Occasionally, recirculation or autotransfusion of evacuated blood from the pleural space is indicated to treat massive haemothorax. In the overwhelming majority of children with significant chest-wall penetrations, tube thoracostomy is the only treatment indicated.
