Management of paediatric spontaneous pneumothorax: a multicentre retrospective case series.

OBJECTIVES: Paediatric guidelines are lacking for management of spontaneous pneumothorax. Adult patient-focused guidelines (British Thoracic Society 2003 and 2010) introduced aspiration as first-line intervention for primary spontaneous pneumothorax (PSP) and small secondary spontaneous pneumothoraces (SSP). Paediatric practice is unclear, and evidence for aspiration success rates is urgently required to develop paediatric-specific recommendations. METHODS: Retrospective analysis of PSP and SSP management at nine paediatric emergency departments across Australia and New Zealand (2003-2010) to compare PSP and SSP management. RESULTS: 219 episodes of spontaneous pneumothorax occurred in 162 children (median age 15 years, 71% male); 155 PSP episodes in 120 children and 64 SSP episodes in 42 children. Intervention in PSP vs SSP episodes occurred in 55% (95% CI 47% to 62%) vs 70% (60% to 79%), p<0.05. An intercostal chest catheter (ICC) was used in 104/219 (47%) episodes. Aspiration was used in more PSP than in SSP episodes with interventions (27% (18% to 37%) vs 9% (3% to 21%), p<0.05). Aspiration success was 52% (33% to 70%) overall and not significantly different between PSP and SSP. Aspiration success was greater in small vs large pneumothoraces (80% (48% to 95%) vs 33% (14% to 61%), p=0.01). Small-bore ICCs were used in 40% of ICCs and usage increased during the study. CONCLUSIONS: In this descriptive study of pneumothorax management, PSP and SSP management did not differ and ICC insertion was the continuing preferred intervention. Overall success of aspiration was lower than reported results for adults, although success was greater for small than for large pneumothoraces. Paediatric prospective studies are urgently required to determine optimal paediatric interventional management strategies.

Paediatric analgesia in the emergency department, are we getting it right?

OBJECTIVES: To measure the dose discrepancy in prescribing simple paediatric analgesia, in the emergency department, by comparing age and actual weight-based dosing. To establish the accuracy of the weight-estimation formula for children [weight kg=2 (age years+4)]. METHODS: A prospective survey conducted in the emergency departments of a UK teaching hospital and district general hospital. Two hundred and forty-seven children were prescribed simple analgesia in the form of paracetamol and ibuprofen or both. The dose prescribed was based on age. All children were weighed and a maximum dose based on the child's weight was calculated. The individual child's weight was also compared with the weight calculated using the estimation formula. RESULTS: A total of 247 patients were included. Two hundred and thirty-three patients were prescribed paracetamol. Fifteen patients were prescribed ibuprofen. The paracetamol group was administered a mean dose that was 67% (P<0.001) of the optimal dose that was based on weight. Ibuprofen dosage was 51% (P<0.001) of optimal dose. The weight-estimation formula underestimated weight by 16% (P<0.001). CONCLUSIONS: Prescribing analgesia by age often results in significant underdosing in the paediatric population. Predicting a child's weight using the calculation may result in underdosing.