PNEUMOTHORAX IN CHILDREN Case Report

CASE REPORT
RESPIROLOGY DIVISION

SECONDARY SPONTANEOUS PNEUMOTHORAX IN CHILDREN

Mokhammad Ikhsan Nurkholis

Department of Child Health, Medical School, Hasanuddin University /
Wahidin Sudirohusodo General Hospital, Makassar, Indonesia

INTRODUCTION
Pneumothorax is defined as the presence of air or gas in the pleural cavity (ie,
the potential space between the visceral and parietal pleura of the lung), which can
impair oxygenation and/or ventilation. The clinical results are dependent on the
degree of collapse of the lung on the affected side. If the pneumothorax is significant,
it can cause a shift of the mediastinum and compromise hemodynamic stability. Air
can enter the intrapleural space through a communication from the chest wall (ie,
trauma) or through the lung parenchyma across the visceral pleura.1
A primary pneumothorax is one that occurs without an apparent cause and in
the absence of significant lung disease, while a secondary pneumothorax occurs in
the presence of existing lung pathology. In a minority of cases, the amount of air in
the chest increases markedly when a one-way valve is formed by an area of
damaged tissue, leading to a tension pneumothorax. This condition is a medical
emergency that can cause steadily worsening oxygen shortage and low blood
pressure. Unless reversed by effective treatment, these sequelae can progress and
cause death.2
The incidence of spontaneous pneumothorax is 18 per 100,000 men per year
and 6 per 100,000 women per year. It occurs most often in the 20s, and primary
spontaneous pneumothorax rarely occurs over the age of 40. Secondary
spontaneous pneumothorax occurs at any ages. Between 1991 and 1995 the rate of
admissions to United Kingdom hospitals for both primary and secondary
spontaneous pneumothorax was 16.7 per 100,000 men per year and 5.8 per
100,000 women per year. 3

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 1

but in case of secondary spontaneous pneumothorax and traumatic pneumothorax usually require active treatment. the more symptomatic the patient. Iatrogenic pneumothorax does not normally require a chest drain and tension pneumothorax requires immediate attention. Needle aspiration is still favoured as the initial treatment of pneumothoraces. There was history of frequent cough for three month. No fever and seizure complaint on admission. PNEUMOTHORAX IN CHILDREN Case Report The main purpose of treatment pneumothorax is to remove the air from the pleural space and prevent relapses. History taking Her main complaint was sudden onset of shortness breath. needle aspiration and chest drain are all possibilities and the choice will depend upon the severity of the condition. Body weight decreased for the last three months. Simple observation. She felt nausea and vomiting two times. There is much national and international controversy surrounding the 'right' initial treatment of pneumothoraces. She felt chest pain and paroxysmal cough for one week.5 This paper will report a case of secondary spontaneous pneumothorax in 14 years and 8 month old girl. Generally. History of the chest trauma was denied. as this speeds the resolution. Her appetite was decreased. experienced since six hours prior to the admission.Wahidin Sudirohusodo Hospital on November 13. slimy but no dyspnea appearance. Defecation and micturition were normal. but there was history of frequent fever for three months prior to admission. the more active intervention should be utilised. 2012. admitted to pediatric department of dr. There was no contact history with suddenly died poultry. There was no contact history with adult tuberculosis patients. even if there are minimal or no symptoms. She was complaint a bed time sweating for the last one month. CASE REPORT A-14 years and 8 month old girl. Large pneumothoraces should be drained. Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 2 .

Body length (BL) 96 cm. Body weight (BW) 13 kg. there is retraction on suprasternal and subcostal area. Percussion reveals hyper-resonance (hyper-sonor) over the collapse lung. PNEUMOTHORAX IN CHILDREN Case Report Physical examination On physical examination revealed: General condition: She is severely ill.560 /mm3  MCV 84. and conscious state is compos mentis (GCS 15: E4M6V5). She looks distressed and sweating.7 g/dl3  MCHC 33.8 mmHg  SO2 92.454  PO2 61. Peristaltic are normal. BCG vaccine scar was found on the left upper arm.80C.54 x106 /mm3  MCH 28. Chest respiratory movement is assymetrical.9 mmol/L Result: Fully compensated of respiratory alkalosis. Laboratory examination Complete blood count:  White blood count 9.0 pg  Hemoglobin 12.2 mmHg  PCO2 30. Body temperature (BT) 37. Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 3 .4 fl  Red blood count 4. Respiration rate (RR) 60x/menit. Crackles are found on the right lung. Blood pressure (BP) 90/60 mmHg. On palpation examination found crepitations on the left lung. liver and spleen are not palpable. Pulse rate (PR) 120x/menit. nostril breathing was noted. No pale and cyanotic appearances. Breath sounds are reduced or absent over the affected area (left side). nutrition status is under nourish.3 %  Platelet count 317.2 mmol/L  BE -1.2 %  HCO3 21. Solitary and regular heart sound with no murmur heard.000 /mm3 Blood gas analysis:  pH 7. there is no wheezing appearance.2 g/dl  Hematocrit 38.

1 mmol/l. Antero Posterior chest X-ray result: CT Scan Thorax result:  Left pneumothorax  Left pneumothorax with lung  Lung tumor suspected colaps  Infected bronchiectasis dextra Advice : Thorax CT scan  Chronic active of duplex tuberculosis Figure 1. chloride 112 mmol/l. PNEUMOTHORAX IN CHILDREN Case Report Blood glucose level 108 mg/dl SGOT 14 U/L SGPT 8 U/L HBsAg (Rapid) negative Anti HCV negative Bleeding time 8’00’’ minutes Clothing time 2’00 minutes Prothrombin time 10. Patient thorax x-ray Figure 2. potassium 4.9 second Activated Partial Thromboplastin Time 27.3 second Electrolytes: Sodium 144 mmol/l. Patient thorax CT scan Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 4 .

ranitidine 2 x 25 mg/iv. ketorolac injection 2 x 10 mg/iv. IVFD D5% 30 gtt/mnt.  Tuberculin test FURTHER OBSERVATIONS 2nd day of treatment (14 November 2012) General condition: weak BP 90/60 mmHg.0 0C Fever and headache was absent. mucus and shortness of breath was positives. BT 37. No other new complaints from the patient. ceftriaxon injection 2 x 1 g/iv. Asymmetrical movement of the chest wall when breathing was noted. RR 50x/mnt. On chest auscultation found decreased breath sounds on the left lung.. Planning: WSD procedure and Tuberculin test. Cough. PNEUMOTHORAX IN CHILDREN Case Report Working Diagnosis:  Left Pneumothorax  Lung tuberculosis suspected  Under nourish Managements Supporting therapy:  O2 2 L/min via nasal canule  Intra Venous Fluid Displacement Dextrose 5% 30 gtt/min Medicamentosa:  Ceftriaxon injection 2 x 1 g/iv  Ketorolac injection 2 x 10 mg/iv  Ranitidine injection 2 x 25 mg/iv Diet therapy:  Usual diet o Calorie 2000 gr o Protein 75 gr Planning  Consult to surgical department for water sealed drainage (WSD) procedure. On physical examination nostril breathing and suprasternal retractions still appear. PR 140x/mnt. Usual dietary intake. Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 5 . O2 2 L/min via nasal canule. crackles are still audible in right lung.

Her appetite was improved. WSD was attached. On physical examination nostril breathing and suprasternal retractions still appear. Usual dietary intake. ketorolac injection 2 x 10 mg/iv. Read of tuberculin test tomorrow 4th day of treatment (16 November 2012) General condition: weak BP 110/70 mmHg. Rifampicin 1 x 450 mg/oral. Positive result of tuberculin test Planning: Continued therapy. Tuberculin test result (+) induration 30 mm. RR 20 x/mnt. WSD still attached.7 0C Cough was negative and shortness of breath was reduced. Isoniazid 1 x 300 mg/oral. On physical examination nostril breathing was disappeared and suprasternal retractions was minimal. IVFD D5% 30 gtt/mnt. Usual dietary intake. On chest auscultation found left lung breath sounds was improved. ranitidine 2 x 25 mg/iv. Positive result of tuberculin test Figure 4. Thorax x-ray control Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 6 . No other new complaints from the patient. RR 36 x/mnt. (Sokal methods) Figure 3. She refused routine blood test. PR 80 x/mnt. Her appetite still decreased. ceftriaxon injection 2 x 1 g/iv. On chest auscultation found decreased breath sounds on the left lung. Pirazinamid 2 x 250 mg/oral. O2 2 L/min via nasal canule. crackles are audible in both lung. PR 96 x/mnt. No other new complaints from the patient. Asymetrical movement of the chest wall was disappeared. BT 36. Asymetrical movement of the chest wall when breathing was improved. IVFD D5% 30 gtt/mnt. ketorolac injection 2 x 10 mg/iv. PNEUMOTHORAX IN CHILDREN Case Report 3rd day of treatment (15 November 2012) General condition: weak BP 100/60 mmHg. ceftriaxon injection 2 x 1 g/iv. crackles are audible in both lung. ranitidine 2 x 25 mg/iv.8 0C Shortness of breath was disappeared. BT 36. Planning: Routine blood test.

On physical examination retractions was dissapeared. Asymetrical movement of the chest wall was disappeared. ceftriaxon injection 2 x 1 g/iv. BT 36. Planning: Continue therapy Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 7 . Rifampicin 1 x 450 mg/oral. Normal movement of the chest wall. Isoniazid 1 x 300 mg/oral. ketorolac injection 2 x 10 mg/iv. Shortness of breath was disappeared. No other new complaints from the patient. Her appetite was good. Antero Posterior chest X-ray control result:  Pneumothorax sinistra was dissapeared  Specific bilateral pneumonia infection Figure 5. Stop chest tube (WSD) 6th day of treatment (18 November 2012) General condition: active BP 110/70 mmHg. Her appetite was good. crackles are audible in both lung. PR 96 x/mnt. WSD still attached. IVFD D5% 30 gtt/mnt. On physical examination retractions was negative. Usual dietary intake. RR 20 x/mnt. ranitidine 2 x 25 mg/iv. BT 36. Thorax x-ray. RR 20 x/mnt. crackles are audible in both lung. before and after treatment Planning: Continue therapy. Pirazinamid 2 x 250 mg/oral. No other new complaints from the patient. PR 100 x/mnt.7 0C Cough and shortness of breath was negatives. On chest auscultation found left lung breath sounds was normal.8 0C Cough was negative. PNEUMOTHORAX IN CHILDREN Case Report 5th day of treatment (17 November 2012) General condition: weak BP 110/70 mmHg. On chest auscultation breath sounds was normal.

On auscultation breath sounds was normal. IVFD D5% 30 gtt/mnt. Her appetite was good. crackles are audible in both lung. crackles are audible in both lung. ranitidine 2 x 25 mg/iv. ceftriaxon injection 2 x 1 g/iv. Isoniazid 1 x 300 mg/oral. ketorolac injection 2 x 10 mg/iv. No other new complaints from the patient. Rifampicin 1 x 450 mg/oral. On physical examination retractions was negative. Rifampicin 1 x 450 mg/oral. Her appetite was good. Symmetrical movement of the chest wall. PNEUMOTHORAX IN CHILDREN Case Report 7th day of treatment (19 November 2012) General condition: active Vital sign was in normal range. ketorolac injection 2 x 10 mg/iv. Pirazinamid 2 x 250 mg/oral. ranitidine 2 x 25 mg/iv. On physical examination retractions was negative. IVFD D5% 30 gtt/mnt. No other new complaints from the patient. Cough and shortness of breath was negatives. Her appetite was good. Rifampicin 1 x 450 mg/oral. Isoniazid 1 x 300 mg/oral. On auscultation breath sounds was normal. ceftriaxon injection 2 x 1 g/iv. Usual dietary intake. On physical examination retractions was negative. crackles are audible in both lung. Pyridoxine 2 x 40 mg/oral. ketorolac injection 2 x 10 mg/iv. On auscultation breath sounds was normal. Isoniazid 1 x 300 mg/oral. Cough and shortness of breath was negatives. No other new complaints from the patient. Planning: Continue therapy Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 8 . Symmetrical movement of the chest wall. Planning: Continue therapy 9th day of treatment (21 November 2012) General condition: active Vital sign was in normal range. ranitidine 2 x 25 mg/iv. Pyridoxine 2 x 40 mg/oral. Pirazinamid 2 x 250 mg/oral. IVFD D5% 30 gtt/mnt. ceftriaxon injection 2 x 1 g/iv. Symmetrical movement of the chest wall. Planning: Continue therapy 8th day of treatment (20 November 2012) General condition: active Vital sign was in normal range. Pirazinamid 2 x 250 mg/oral. Cough and shortness of breath was negatives. Usual dietary intake. Usual dietary intake.

The bronchi then divide into smaller and smaller branches (bronchioles). stop intravenous therapeutic drug. which contains blood vessels and cells that help support the alveoli. ranitidine 2 x 25 mg/iv. Usual dietary intake. IVFD D5% 30 gtt/mnt. Pirazinamid 2 x 250 mg/oral. air-filled organs located on either side of the chest (thorax). Her mother asking for discharge from hospital and planning to continue therapy at home. called bronchi. Her appetite was good. Planning: Continue oral therapy. ceftriaxon injection 2 x 1 g/iv. finally becoming microscopic. Isoniazid 1 x 300 mg/oral. PNEUMOTHORAX IN CHILDREN Case Report 10th day of treatment (22 November 2012) General condition: good Vital sign was in normal range. Pyridoxine 2 x 40 mg/oral. Rifampicin 1 x 450 mg/oral. oxygen from the air is absorbed into the blood. No other new complaints from the patient. The bronchioles eventually end in clusters of microscopic air sacs called alveoli. In the alveoli. On auscultation breath sounds was normal. Definitive diagnosis  Left spontaneous secondary pneumothorax  Lung tuberculosis  Under nourish Prognosis Qua ad vitam : ad bonam Qua ad sanationem : ad bonam DISCUSSION The lungs are a pair of spongy. Cough and shortness of breath was negatives. where it can be exhaled. Between the alveoli is a thin layer of cells called the interstitium. crackles are audible in both lung. Carbon dioxide. ketorolac injection 2 x 10 mg/iv. Symmetrical movement of the chest wall.7 Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 9 . On physical examination retractions was negative. travels from the blood to the alveoli. a waste product of metabolism. The trachea (windpipe) conducts inhaled air into the lungs through its tubular branches.

also called pleura. The clinical results are dependent on the degree of collapse of the lung on the affected side. trauma) or through the lung parenchyma across the visceral pleura. The same kind of thin tissue lines the inside of the chest cavity -. A thin layer of fluid acts as a lubricant allowing the lungs to slip smoothly as they expand and contract with each breath.7 Pneumothorax is defined as the presence of air or gas in the pleural cavity (ie. Air can enter the intrapleural space through a communication from the chest wall (ie. the potential space between the visceral and parietal pleura of the lung). Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 10 .1 Figure 6: Overview of the lungs in pneumothorax (cited from literature 6) Pneumothoraces can be classified according to etiology: 4  Primary spontaneous pneumothorax occurs with no previous lung disease but there are tiny blebs that are foci of weakness. it can cause a shift of the mediastinum and compromise hemodynamic stability. PNEUMOTHORAX IN CHILDREN Case Report The lungs are covered by a thin tissue layer called the pleura. which can impair oxygenation and/or ventilation. If the pneumothorax is significant. It usually affects a young adult.

that can be detected by CT scanning. PNEUMOTHORAX IN CHILDREN Case Report  Secondary spontaneous pneumo thorax occurs in slightly older subjects with underlying lung disease. thin. many patients whose condition is labeled as primary spontaneous pneumothorax have subclinical lung disease.  Traumatic pneumothorax follows a penetrating chest trauma such as a stab wound. Patients are typically aged 18-40 years. Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 11 . are smokers.  Iatrogenic pneumothorax may follow a number of procedures such as mechanical ventilation and interventional procedures such as central line placement. lung biopsy and percutaneous liver biopsy.1 Figure 7.*** * Radiograph of a patient with a small spontaneous primary pneumothorax ** Close radiographic view of patient with a small spontaneous primary pneumothorax (same patient as from the previous image). *** Expiratory radiograph of a patient with a small spontaneous primary pneumothorax (same patient as in the previous images). In other words.  Catamenial pneumothorax refers to pneumothorax at the time of menstruation. It represents 3-6% of spontaneous pneumothorax in women. air enters into the intrapleural space without preceding trauma and without an underlying history of clinical lung disease. The aetiology is endometriosis. However. tall. Spontaneous pneumothorax is a commonly encountered problem with approaches to treatment that vary from observation to aggressive intervention. often.** Figure 9. Primary spontaneous pneumothorax (PSP) occurs in people without underlying lung disease and in the absence of an inciting event (see the images below). and. such as pleural blebs.* Figure 8. gunshot injury or a fractured rib. It usually follows rupture of a congenital bulla or a cyst in chronic obstructive pulmonary disease (COPD).

The presentation of these patients may include more serious clinical symptoms and sequelae due to comorbid conditions.9 % estimate size of pneumothorax A + B + C (cm) 3 Figure 10: % estimate size of pneumothorax (cited from literature 9) 2. then divided by three. or compromised alveoli. among others: 1. and multiplied by ten.10 % estimate size of Lung collaps (AxB) – (axb) cm AxB Figure 11: % estimate size of Lung collaps (cited from literature 10) Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 12 . Air enters the pleural space via distended. damaged. Summing the furthest distance between the slit pleura on vertical lines. The ratio between the difference hemitoraks broad and extensive lung collapse hemitoraks divided by the area multiplied by 100%. plus the furthest distance between the slit pleura on the horizontal line. coupled with the shortest distance between pleural gap on the horizontal line.1 There are several methods that can be used in determining the extent of lung collapse. These individuals have underlying pulmonary pathology that alters normal lung structure. PNEUMOTHORAX IN CHILDREN Case Report Secondary spontaneous pneumothorax (SSP) occurs in people with a wide variety of parenchymal lung diseases.

11 Figure 12: % estimate size of pneumothorax (cited from literature 11) In our case. Such as sudden respiratory pain. separated from the parietal pleura (and chest wall) by a lucent gas space devoid of pulmonary vessels. The pleural line appears in the radiologic image. To express the pneumothorax size as a percentage. If lateral edge of lung is > 2cm’s from thoracic cage at the level of the hilum. there is no wheezing appearance.9 On physical examination. Mentioned in an extensive literatures that when the percentage of pneumothorax >50% and a collapsed lung area is <50%. the suspicious symptom of pneumothorax was noted. respiratory distress. known as the pleural line. adequate treatment should be given immediately. then this implies pneumothorax is at least 50%. the calculation of percent area of pneumothorax is 80%. Breath sounds are reduced or absent over the affected area (left side). Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 13 . asymmetrical respiratory movement. multiply the fractional size by 100. Calculate the ratio of the transverse radius of the pneumothorax (cubed) to the transverse radius of the hemithorax (cubed). Hence. Crackles are found on the right lung. and percent of collapsed lung area is 20% (estimated calculation with the first method). The diagnosis of pneumothorax is established by demonstrating the outer margin of the visceral pleura (and lung). hyper-resonance (hyper-sonor) over the collapse lung. chest wall retractions. PNEUMOTHORAX IN CHILDREN Case Report 3. Small pneumothorax is equivalent to <30%. this mean the patient has a large pneumothorax.1 Chest x-ray or thorax CT scan was the essential investigation to confirm the presence of pneumothorax.

PNEUMOTHORAX IN CHILDREN Case Report On the chest x-ray we evaluate of a typical description such:  The air contain area would seem hiperluscen without lung tissue appereance. The percent area of pneumothorax as calculated in earlier discussion. sometimes a collapsed lung but did not form a line according to the lobe-shaped pulmonary lobuler. spatium widened intercostal. Figure 13: Pneumothorax chest x-ray. diaphragm down flat and depressed. concluded that the patient has a large pneumothorax. Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 14 . diaphragm down flat and depressed. This area was avaskuler because the lung tissue was collapse.  When accompanied by blood or fluid. The x-ray image shown a wide hiperluscen area on the left hemithorax. Heart and trachea pushed to the healthy side. Important clinical point of this relationship is that when there is the presence of a large pneumothorax adequate treatment should be given immediately.  Heart and trachea pushed to the healthy side. it would seem that a horizontal line is the boundary between air and liquid. (cited from literature 11) The first chest x-ray examination result in patient was left pneumothorax. Heart and trachea pushed to the healthy side. spatium widened intercostal. the lung collapse would seem that the line is the edge of the lung.  Lung tissue collapses looked like a radio opaque mass in the hilar region.

 Reduce the pressure of the thorax by make a connection between the pleural cavity with outside air. and initiate WSD with VATS guided. and provision of O2. close observation and monitoring. Figure 14: Flowchart of management of spontaneous pneumothorax. (Video-assisted thoracoscopic ~ surgery)  Thoracotomy and pleurodesis if necessary. PNEUMOTHORAX IN CHILDREN Case Report The principle management of large pneumothorax is:  Stabilized vital sign. In the literature one also mentioned that if there are other processes in the lung is an additional treatment directed against the cause has to be considered. (cited from literature 10) The determination of conservative treatment or surgical intervention is based on clinical manifestations and confirmed by the results of chest x-ray images. Installation of water sealed drainage is base on the percent area of pneumothorax > 25% and intravenous antibiotics are prepare to treat underlying causes of pneumothorax. Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 15 .  Investigate directly into the thoracic cavity with thoracoscope.

before water sealed drainage procedure. Secondary spontaneous pneumothorax had a recurrence rate of 39-47%. physical and supporting examinations (chest x-ray. Intravenous antibiotic was given as a prophylaxis therapy for this invasive procedure. Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 16 . thorax CT scan and arterial blood gas analysis). then multidrug therapy for the underlying disease was prescribed. Figure 14: Patient with pneumothorax. Intervention and observation evaluated base on improvement of the clinical symptoms. Prognosis varies according to the cause of pneumothorax. Figure 15: Patient with pneumothorax. PNEUMOTHORAX IN CHILDREN Case Report Prognosis of the patient are bonam (qua ad vitam and qua ad sanationem) because adequate management are initiated and clinical symptoms were improved within a week. The management of this patient is to remove the trap air with water sealed drainage procedure. after water sealed drainage procedure. was reported. The prognosis of the patient was good. Diagnosis was based on history. SUMMARY A case of pneumothorax in a 14 year 8 month old girl. As mention that the patient has a tuberculosis infection.

Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 17 . PNEUMOTHORAX IN CHILDREN Case Report Figure 16: Water sealed drainage procedure. (cited from literature 10) Figure 17: Patient with pneumothorax. first control at OPD (one week after discharge).

39-52 Presented at Pediatric Department of Hasanuddin University on 21th June 2013 | 18 .rch. Korom S. Catamenial pneumothorax revisited: clinical approach and systematic review of the literature. Sahn SA.55:666-71. 4. J Thorac Cardiovasc Surg.1995:1127-30 10. Conor DC. June 22. European Respiratory Journal.au/clinicalguide/guideline_index/Primary_Spontaneous_Pneumothorax/ 9. 2005. Gupta D.com/pneumothorax/article. Epidemiology of pneumothorax in England. Primary Spontaneous Pneumothorax.htm 7.28(3):637–50. Department of Respiratory Medicine Leeds UK 2003. Curr Opin Pulm Med. Astoul P. 2010 Feb. Hansell A. AJRad. 2009 Jul. Heffner JE.15:376-9.128(4):502-8. Henry M. Simon Y. Thorax. Lung. Arnold T. Spontaneous pneumothorax. John Harvey. Tschopp JM. Mason RM. Kelly AM. 2004 Oct. 2000 Aug. George Schiffman. 2013 June 10 [cited 2013 June 20]. 2. 5. 2012 Nov 05 [cited 2013 June 20]. Available from: http://www.medicinenet. Treatment of primary spontaneous pneumothorax. Management of spontaneous pneumothorax: state of the art. Rami-Porta R. Noppen M. 8. Nadel's Textbook of Respiratory Medicine 4th Ed.18-31 11. N Engl J Med. Elsevier Saunders. Andrew MD. 3. 2000.org. Management of spontaneous pneumothorax. et al. Canyurt H. Pneumothorax (Collapsed Lung). Available from: http://www. British Thoraces Society.342(12):868-74. 6. PNEUMOTHORAX IN CHILDREN Case Report REFERENCES 1. Anthony Arnold. Quantification of pneumothorax size in radiograph using inter-pleural distances. Missbach A. BTS guidelines of spontaneous pneumothorax.