The optimal timing of operative management in children with primary spontaneous pneumothorax (PSP) remains controversial. This study sought to determine early risk factors for failure of chest tube nonoperative management during the initial hospitalization in adolescents with PSP.A retrospective review was conducted for children (aged ≤18 years) admitted to a single tertiary care referral center for their first presentation of a PSP managed with at least 48 h of chest tube decompression (CTD) alone. Patient outcomes and early risk factors for operative management were analyzed by multivariate regression.Of the 39 patients who met inclusion criteria, 15 (38.5%) patients failed nonoperative treatment while 24 (61.5%) patients were managed with CTD therapy alone. Progression to thoracoscopic surgery was associated with longer CTD of 8 vs 3 days and hospital length of stay of 9 vs 4 days when compared to nonoperative management (p 0.001, both). Air leak and increase in pneumothorax size at 24 h after CTD were independently associated with progression to surgery (p = 0.007, p = 0.002). Combined, these risk factors were associated with a significant increase in recurrence (OR 6.00, 95% CI 1.11-41.11, p = 0.048). There were no significant differences between PSP management strategies regarding cumulative radiation exposure or 2 year recurrence.Air leak or increasing pneumothorax size within 24 h of CTD are highly correlated with failed nonoperative management during the initial hospitalization in pediatric patients with PSP. This data may be useful in the development of pediatric-specific treatment algorithms to optimally manage these patients.Treatment study, Level III.
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