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Management of Primary Spontaneous Pneumothorax in Children

Emmanuelle Seguier-Lipszyc, Arnon Elizur, Baruch Klin, Michael Vaiman and Gad Lotan CLIN PEDIATR 2011 50: 797 originally published online 11 April 2011 DOI: 10.1177/0009922811404699 The online version of this article can be found at: http://cpj.sagepub.com/content/50/9/797

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Articles

Management of Primary Spontaneous Pneumothorax in Children

Clinical Pediatrics 50(9) 797802 The Author(s) 2011 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922811404699 http://cpj.sagepub.com

Emmanuelle Seguier-Lipszyc, MD1, Arnon Elizur, MD1, Baruch Klin, MD1, Michael Vaiman, MD, PhD1, and Gad Lotan, MD1

Abstract Objective. To examine the role of CT scans and early surgical intervention in the management of pediatric patients with primary spontaneous pneumothorax (PSP). Methods. Retrospective cohort study. Results. The authors identified 46 cases with 70 episodes of pneumothorax. The recurrence rate among conservatively treated patients was 50% both after the first and the subsequent episode. Recurrence rate in cases with and without blebs on CT was comparable. Initial episodes were treated with supplemental oxygen (n = 18) and chest tube drainage (n = 18), and 10 patients underwent video-assisted thoracoscopic surgery (VATS). The recurrence rate was significantly lower following surgical intervention compared with other therapy, and morbidity was comparable with that in patients who needed chest tube drainage. Conclusions. Recurrence after the first episode of PSP in children is frequent and is difficult to predict by CT findings. VATS is safe and effective in preventing recurrences. Surgical intervention may be an attractive alternative in patients who require chest tube drainage for the first episode of PSP. Keywords pediatric, pneumothorax, thoracoscopic surgery

Introduction
The controversy in the management of the primary spontaneous pneumothorax (PSP) still exists and revolves around 2 issues: supplemental oxygen versus chest tube drainage versus surgery and the necessity of performing a chest CT scan for a first episode of PSP in children. PSP remains a significant health problem with an annual incidence of 18 to 28 per 100 000 population in boys and 1.2 to 6 per 100 000 in girls in Great Britain, with similar figures in Sweden.1,2 Retrospective pediatric studies suggest a lower incidence in children, but the true incidence in the pediatric population remains unclear.3-7 Tall, thin boys with a below-average body mass index are typically affected.7 It is generally considered that PSP results from the rupture of bullae or blebs in the apices of the lung without an underlying predisposing lung disease or history of trauma.8,9 Although bullae and blebs are usually not visible on plain chest radiographs, they can often be visualized with the use of computed tomography (CT) scans.8 Some studies have found that patients with bullae on chest CT have a greater risk of recurrence of PSP than those without,10,11 but others could not find a similar

correlation.12,13 Therefore, the utility in performing a chest CT scan for a first episode of PSP in children remains controversial, and it is recommended only in selected populations. The goal in the management of PSP is to treat the acute episode and prevent recurrence with minimal morbidity. Definitive treatment such as bulbectomy or pleural pleurodesis has been shown to reduce the recurrence rate but is associated with significant morbidity.14 With the advent of video-assisted thoracoscopic surgery (VATS), definitive treatment can be achieved with low morbidity.15-17 However, many aspects about the management of PSP in children and the best way to prevent recurrences are still controversial. The challenge in developing a standardized approach for the management of pediatric PSP is a result of the fact that most available data in children is extrapolated from adult studies that include pediatric patients or is derived
1

Assaf Harofe Medical Center, Zerifin, Israel

Corresponding Author: Michael Vaiman, 33 Shapira Street, Bat Yam, Israel 59561 Email:vaimed@yahoo.com

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798 from small pediatric studies. In this study, we report 10 years of experience in the management of PSP in a selective pediatric patient population. As the number of patients in our study is relatively large, we aimed to examine the role of CT scans and early surgical intervention in the management of these patients.

Clinical Pediatrics 50(9)

Statistical Analysis
Analyses were performed using SPSS 16.0 for Windows. Pearsons or Fishers exact tests were used to analyze the relationship between categorical variables. The unpaired Students t test and the 1-way ANOVA with Tukeys HSD post hoc analyses were used to analyze the relationship between continuous variables. Values are expressed as means standard deviation unless otherwise stated. A significance level of P < .05 was chosen.

Methods
In a retrospective cohort study, the medical records of children with PSP that were admitted to the Pediatric Surgery Department at Assaf Harofeh Medical Center from 1999 to 2009 were reviewed. All children aged <18 years who were admitted with an episode of spontaneous pneumothorax were included. Children with underlying lung diseases, malignancy, infection, connective tissue disease, or congenital lung disease were excluded. Children with mild intermittent asthma managed on an outpatient basis because of asthma were not excluded if they had minimal or no chronic symptoms during the day or night, minimal or no exacerbations, no limitations on activities, and so on. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori after approval by the institutions Helsinki committee (Protocol No. 201/09). Demographic characteristics (age, gender, weight, height, history of smoking, and comorbidities), symptoms and signs on presentation, laboratory studies (chest CT), initial management (observation vs chest tube drainage vs surgery), and outcome (complications and length of stay) were obtained. Patients were contacted by telephone and asked about subsequent episodes of PSP, admissions, and surgeries. Patients were also asked about their smoking habits following the first episode. The policy for managing patients with PSP at our center consists of supplemental oxygen alone when the pnemothorax is small and chest tube drainage when the pneumothorax is of moderate size or large. High-resolution CT studies of the lungs were offered to patients who were treated either with supplemental oxygen alone or who required chest tube drainage, and these were performed randomly per patients choice after discharge. VATS was performed in cases of prolonged air leak (more than 7 days) or in the presence of blebs or bullae on CT scan. All surgical procedures included removal of identified blebs or bullae with pleurodesis involving mechanical abrasion of the pleura and instillation of talc to stimulate an inflammatory response. Patients with recurrent and those with nonrecurrent PSP were compared, and the utility of performing a CT scan and the role of VATS in the management of a first episode of PSP were examined.

Results
Between 1999 and 2009, 46 children presented to the Asaf Harofeh Pediatric Surgery Department with 70 episodes of PSP; 40 patients (87%) were male, and the mean age at presentation was 16.2 years (range 10.3-18 years). Of these children, 4 boys had a history of smoking, 4 children had underlying asthma, and 1 patient had idiopathic scoliosis; 2 children had a family history of PSP. In all, 45 of the 46 initial episodes of PSP were unilateral (29 left sided and 16 right sided), and 1 was bilateral at presentation. The main initial symptoms on presentation in all 70 episodes were chest pain (83%), breathlessness (30%), back and shoulder pain (14%), and cough (3%). In all, 20 patients (43.5%) had recurrences, but the recurrence rate among patients who were treated either with supplemental oxygen or with chest tube drainage was 50%. Patients with recurrent and those with nonrecurrent episodes of PSP were comparable for age, gender, side of pneumothorax, and length of symptoms prior to admission (Table 1). Comparable numbers of patients in both groups underwent CT as part of their evaluation, and the rate of abnormalities on CT scan (blebs or bullae) was also comparable. More patients in the group with recurrent PSP were treated conservatively with supplemental oxygen alone, and fewer patients were treated surgically, although these differences did not reach statistical significance. The mean length of stay in the hospital was significantly shorter in this group than in the group of patients with nonrecurrent PSP (Table 1). The length of follow-up of patients in the 2 groups after hospitalization was similar. Among the 46 initial episodes, 29 underwent CT, which demonstrated blebs or bullae in 13 patients (44.8% of imaged events; Table 2). In 11 of those who had an abnormal CT, the abnormality was found on the side of the pneumothorax; in 1 patient with a left pneumothorax, bilateral apical bullae were found; and in 1 patient who had bilateral pneumothoraces, bullae were found only on 1 side. Treatment varied significantly between groups

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Seguier-Lipszyc et al.
Table 1. Comparison of Patients With Nonrecurrent Versus Recurrent PSP Nonrecurrent PSP (n = 26) Mean age (years) Male gender Mean length of symptoms (hours) Left-sided pneumothorax Underwent CT scan Abnormalities on CT scan (percentage of CT) Treatment O2 alone Chest tube + O2 VATS Mean length of stay (days) Mean length of follow-up (years) 16.3 1.8 23 (88.5%) 23.6 65.9 17 (65.4%) 16 (61.5%) 8 (50%) 8 (30.8%) 10 (38.5%) 8 (30.8%) 6.7 7.4 5.3 3.1
a

799

Recurrent PSP (n = 20) 16.2 1.5 17 (85%) 24.8 42.6 12 (60%) 13 (65%) 5 (38.5%) 10 (50%) 8 (40%) 2 (10%) 3.7 1.6 5.5 3

P Value .9 1.0 .95 .51 1.0 .71 .23 1.0 .15 .05 .78

Abbreviations: PSP, primary spontaneous pneumothorax; CT, computed tomography; VATS, video-assisted thoracoscopic surgery. a Numerical variables are expressed as mean standard deviation.

Table 2. Comparison of Patients Based on CT Findings No CT (n = 17) Mean length of stay (days) Treatment O2 alone Chest tube + O2 VATS Mean length of follow-up (years) No. of patients with recurrence 6.3 9 9 (52.9%) 6 (35.3%) 2 (11.8%) 6.5 3.2 7 (41.2%)
a

Normal CT (n = 16) 5.1 2.8 7 (43.8%) 8 (50%) 1 (6.2%) 5.6 3.4 8 (50%)

Abnormal CT (n = 13) 4.7 2.4 2 (15.4%) 4 (30.8%) 7 (53.8%) 3.9 1.7 5 (38.5%)

P Value .7 .1 .53 .004 .08 .8

Abbreviations: CT, computed tomography; VATS, video-assisted thoracoscopic surgery. a Numerical variables are expressed as mean standard deviation.

with various tomography findings: more patients with abnormal CTs underwent VATS compared with patients with normal CTs (P = .01) or patients who did not undergo a CT (P = .02). However, the rate of recurrence was not significantly different between the groups. Also, 6 patients with abnormalities on CT scan declined VATS. These patients were treated with chest tube drainage. It was then explained to the parents of these patients that if recurrence did occur, VATS would be the preferable choice of treatment. When comparing rates of recurrence based on CT findings only in patients who were treated either with supplemental oxygen or with chest tube drainage, again, no significant differences were found (46.7% recurrence in patients without CT [n = 15], 53.3% in patients with normal CT [n = 15], and 50% in those with abnormal CT [n = 6]; P = .94). Among the 46 initial episodes, 36 were treated conservatively (18 episodes were treated with supplemental oxygen alone and 18 episodes required the insertion of a chest tube), and 10 episodes required VATS (Table 3). VATS was performed in 7 patients because of abnormalities

on CT scan and in 3 patients because of prolonged air leak of more than 7 days, probably accounting for the higher rate of abnormalities on CT in surgically treated patients (P = .015) and for their longer mean length of stay (11.1 10.5 days) compared with patients treated either with supplemental oxygen or with chest tube drainage. Postsurgical length of stay, however, was comparable to length of stay following chest tube insertion (P = .97). None of the patients treated with VATS had ipsilateral recurrence compared with 44% in patients who required chest tube drainage and 44% in patients treated with supplemental oxygen (P = .033). The mean length of stay after surgery was 4.8 days (range, 2-8 days). Two children presented with postoperative complications (one with fever and one with phlebitis) that were treated successfully with a course of IV antibiotics. Of the 20 patients with recurrences, 15 had 1, and 5 patients had 2 recurrent episodes. Of the 25 recurrent episodes, 19 (76%) were ipsilateral, and 6 were contralateral. The mean interval between the first and second episode was 4.3 months (range 1-55 months), and all

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Table 3. Comparison of Different Treatment Approaches O2 Alone (n = 18) Mean length of stay (days) Complications CT after first episode (percentage of patients) Abnormal CT (percentage of CT) Mean length of follow-up (years) Recurrence Ipsilateral Contralateral 2.9 0.9a 0 9 (50%) 2 (22.2%) 5.4 3.5 8 (44.4%) 2 (11.1%) Chest Tube (n = 18) 4.8 1.8 1 (5.6%) 12 (66.7%) 4 (33.3%) 5.5 2.6 8 (44.4%) 0

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VATS (n = 10) 4.8 1.6 2 (20%) 8 (80%) 7 (87.5%) 5.1 3.3 0 2 (20%)

P Value .001 .12 .27 .015 .95 .033 .18

Abbreviations: VATS, video-assisted thoracoscopic surgery; CT, computed tomography. a Numerical variables are expressed as mean standard deviation.

recurrences but one were during the first year following the initial episode. Following the second episode, 12 patients were treated surgically. Only 1 surgically treated patient (8.3%) had a third recurrence, which was contralateral, compared with 4 of 8 patients (50%) who were not treated surgically after the second episode (P = .033).

Discussion
The goal in the management of PSP is to treat the acute episode and prevent recurrence, with minimal morbidity. The risk of recurrence after the first episode of PSP in adults averages 30% and increases to up to 62% for a second recurrence and 83% for a third.13,16,18 Definitive surgical management for PSP in adults is usually offered after a second episode. This approach is based in part on this marked difference in rate of recurrence between the first and consecutive episodes.13 In children, the risk of recurrence following the first episode of PSP is higher, ranging from 50% to 60%.7,16,19 We found a similar recurrence rate of 50% in children treated either with supplemental oxygen or with chest tube drainage. Moreover, the recurrence rate after a first versus a second episode in our patients was similar. In addition, the fear of recurrence may limit activities of both the patient and the family. Taken together, these findings suggest that surgical treatment for PSP in children may need to be considered sooner. Some studies suggest that family selection for workup and treatment after a single episode of PSP may be reasonable depending on lifestyle and access of a child to emergency care,3,4,7,9 but these may apply to only a small number of patients. The pathophysiology of PSP remains unknown. It is generally considered to be the result of rupture of blebs and bullae in the apices of the lungs, but this theory has been questioned.13 Blebs and bullae are best visualized on CT scan and can be detected in 81% of otherwise healthy adults with previous PSP but also in 20% of matched controls.20,21 Some adult studies showed that

bullae are associated with significantly higher contralateral occurrence after unilateral PSP, but others could not demonstrate a similar correlation.10,20,22 In children, blebs and bullae can be found on CT in 28% to 56% of patients with PSP but not in healthy controls and were found by some to be associated with a higher recurrence rate.8,9,11 Whereas several authors recommend routine chest CT for all children with PSP to enable identification and surgical management of subpleural blebs, others do not support such an approach.7,8,10,11,22,23 Specifically, the authors of the recent evidence-based study23 suggest that the presence of apical lung cysts or bullae is not predictive of recurrence and that the decision for surgical intervention should be based on documented recurrence only. Establishing a standardized approach is difficult as the data in children are based on small studies. We found apical lung blebs in 13 children (44.8%) and demonstrated that the rate of recurrence even in patients with a normal CT is high and is comparable to the recurrence rate in patients with blebs on CT. As CT findings do not appear to be useful in predicting recurrence or in reassurance of low recurrence risk, other criteria for surgical management after the initial episode of PSP need to be established. Small pneumothoraces can be treated with supplemental oxygen alone, but larger or persistent air leaks should be drained. Simple aspiration in adults is still controversial, supported by the British Thoracic Society guidelines but not by the American College of Chest Physicians.24,25 In children, there are only sporadic reports on simple aspiration of PSP, and intercostal chest catheter is standard of care.5 VATS is increasingly performed in children and has been reported to be both safe and effective. It is considered by some as the optimal therapy for childhood empyema26,27 and as more cost-effective in adults with PSP.28 VATS has also been performed with good results in children with primary PSP.15,19 We performed 26 VATS procedures for PSP during the study period (10 for initial episodes) with minimal morbidity.

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Seguier-Lipszyc et al. VATS may therefore be an attractive alternative for patients who require chest tube drainage, because of its effectiveness, minimal invasiveness, and low morbidity and because of the lower recurrence rate associated with its use. Resection of bullae for PSP can now be easily achieved using the thoracoscopic approach, and pleurodesis can be added during the same operation.29 In a clinicopathological correlation study concerning 94 patients presenting with persistent or recurrent PSP treated by VATS, pathomorphological changes were observed in all cases, even when no apical blebs were identified. This observation suggests that systematic pleurodesis is required even in the absence of blebs.30 A recent series comparing the optimal technique of VATS for PSP in children found the combination technique associating chemical or mechanical pleurodesis to blebectomy to be the most acceptable.31 Talc pleurodesis has been shown to be safe and effective in the treatment of spontaneous pneumothorax.32 We used pleurodesis, combining mechanical abrasion and talc pleurodesis with minimal morbidity and low recurrence rates. Thus, our experience adds to the evidence in favor of this technique in children. Our study is limited by the fact that CT scans were performed in outpatient facilities and interpreted by different radiologists. This may lead to suboptimal technique and underdiagnosis of lung blebs. However, the finding of lung blebs in 44.8% of imaged events in our study matches previous reports and does not support underdiagnosis.8,9,11 In general, our opinion is in accord with that of other authors who advocate that VATS may be the preferred route for the treatment of PSP patients with abnormalities visible on CT scans and who require chest tube drainage.

801 data interpretation and writing of the manuscript; and Gad Lotan, MD, guided data collection and interpretation and took part in the writing of the manuscript. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References
1. Melton LJ III, Hepper NGG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950 to 1974. Am Rev Respir Dis. 1979;120:1379-1382. 2. Bense L, Eklund G, Wiman LG. Smoking and the increased risk of contracting spontaneous pneumothorax. Chest. 1987; 92:1009-1012. 3. Shaw KS, Prasil P, Nguyen LT, et al. Pediatric spontaneous pneumothorax. Semin Pediatr Surg. 2003;12:55-61. 4. Qureshi FG, Sandulache VC, Richardson W, et al. Primary vs delayed surgery for spontaneous pneumothorax in children: which is better? J Pediatr Surg. 2005;40:166-169. 5. OLone E, Elphick HE, Robinson PJ. Spontaneous pneumothorax in children: when is invasive treatment indicated? Pediatr Pulmonol. 2008;43:41-46. 6. Wilcox DT, Glick PL, Karamanoukian HL, et al. Spontaneous pneumothorax: a single-institution, 12-year experience in patients under 16 years of age. J Pediatr Surg. 1995; 30:1452-1454. 7. Poenaru D, Yazbeck S, Murphy S. Primary spontaneous pneumothorax in children. J Pediatr Surg. 1994;29: 1183-1185. 8. Choudhary AK, Sellars MEK, Wallis C, et al. Primary spontaneous pneumothorax in children: the role of CT in guiding management. Clin Radiol. 2005;60:508-511. 9. Guimaraes CVA, Donnelly LF, Warner BW. CT findings for blebs and bullae in children with spontaneous pneumothorax and comparison findings in normal age-matched controls. Pediatr Radiol. 2007;37:879-884. 10. Sihoe AD, Yim AP, Lee TW, et al. Can CT scanning be used to select patients with unilateral primary spontaneous pneumothorax for bilateral surgery? Chest. 2000;118: 380-383. 11. Nathan N, Guilbert J, Larroquet M, et al. Efficacy of blebs detection for preventive surgery in childrens idiopathic spontaneous pneumothorax. World J Surg. 2010;34: 185-189. 12. Martinez-Ramos D, Angel-Yepes V, Escrig-Sos J, et al. Usefulness of computed tomography in determining risk of recurrence after a first episode of primary spontaneous

Conclusion
Recurrence after the first episode of PSP in children is frequent and is difficult to predict by CT findings. VATS is safe and effective in preventing recurrences. Surgical intervention may be an attractive alternative in patients who require chest tube drainage for the first episode of PSP. Authors Note Emmanuelle Seguier-Lipszyc, MD, collected the data and took part in the writing of the manuscript; Arnon Elizur, MD, guided data collection and interpretation and took part in the writing of the manuscript; Baruch Klin, MD, assisted in data collection and writing of the manuscript; Michael Vaiman, MD, PhD, assisted in

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pneumothorax: therapeutic implications. Arch Bronconeumol. 2007;43:304-308. Tschopp JM, Rami-Porta R, Noppen M, et al. Management of spontaneous pneumothorax: state of the art. Eur Respir J. 2006;28:637-650. Jimenez-Merchan R, Garcia-Diaz F, Arenas-Linares C, et al. Comparative retrospective study of surgical treatment of spontaneous pneumothorax: thoracotomy vs. thoracoscopy. Surg Endosc. 1997;11:919-922. Ozcan C, McGahren ED, Rodgers BM. Thoracoscopic treatment of spontaneous pneumothorax in children. J Ped Surg. 2003;38:1459-1464. Cook CH, Melvin WS, Groner JI, et al. A cost-effective thoracoscopic treatment strategy for pediatric spontaneous pneumothorax. Surg Endosc. 1999;13:1208-1210. Margolis M, Gharagozloo F, Tempesta B, et al. Videoassisted thoracic surgical treatment of initial spontaneous pneumothorax in young patients. Ann Thorac Surg. 2003;76:1661-1663. Schramel FM, Postmus PE, Vanderschueren RG. Current aspects of spontaneous pneumothorax. Eur Respir J. 1997;10:1372-1379. Butterworth SA, Blair GK, LeBlanc JG, et al. An open and shut case for early VATS treatment of primary spontaneous pneumothorax in children. Can J Surg. 2007;50:171-174. Mitlehner W, Friedrich M, Dissmann W. Value of computer tomography in the detection of bullae and blebs in patients with primary spontaneous pneumothorax. Respiration. 1992;59:221-227. Bense L, Lewander R, Eklund G, et al. Nonsmoking, nonalpha 1-antitrypsin deficiency-induced emphysema in nonsmokers with healed spontaneous pneumothorax, identified by computed tomography of the lungs. Chest. 1993;103:433-438. Ouanes-Besbes L, Golli M, Knani J, et al. Prediction of recurrent spontaneous pneumothorax: CT scan findings versus management features. Respir Med. 2007;101:230-236.

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23. Robinson PD, Cooper P, Ranganathan SC. Evidence-based management of paediatric primary spontaneous pneumothorax. Paediatr Respir Rev. 2009;10:110-117. 24. Henry M, Arnold T, Harvey J. BTS guidelines for the management of spontaneous pneumothorax. Thorax. 2003; 58(suppl 2):ii39-ii52. 25. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001;119:590-602. 26. Avansino JR, Goldman B, Sawin RS, Flum DR. Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis. Pediatrics. 2005;115:1652-1659. 27. Kurt BA, Winterhalter KM, Connors RH, et al. Therapy for parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage. Pediatrics. 2006;118:547-553. 28. Tschopp JM, Boutin C, Astoul P, et al. Talceage by medical thoracoscopy for primary spontaneous pneumothorax is more cost-effective than drainage: a randomized study. Eur Respir J. 2002;20:1003-1009. 29. Tsao K, St Peter SD, Sharp SW, et al. Current application of thoracoscopy in children. J Laparoendosc Adv Surg Tech. 2008;18:131-135. 30. Ayed AK, Chandrasekaran C, Sukumar M. Video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: clinicopathological correlation. Eur J Cardiothorac Surg. 2006;29:221-225. 31. Bialas RC, Weiner TM, Phillips JD. Video-assisted thoracic surgery for primary spontaneous pneumothorax in children: is there an optimal technique? J Ped Surg. 2008;43: 2151-2155. 32. Langenburg SE, Lelli JL. Minimally invasive surgery of the lung: lung biopsy, treatment of spontaneous pneumothorax and pulmonary resection. Semin Pediatr Surg. 2008;17:30-33.

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