Rethinking Primary Spontaneous Pneumothorax in Children and Adolescents: Current Evidence and Evolving Management Strategies

Primary spontaneous pneumothorax (PSP) is increasingly identified in adolescents, but its management is still debated due to a lack of robust pediatric data and a reliance on adult guidelines. As a result, pediatric centers show significant differences in their approaches to diagnosis, imaging, treatment decisions, surgical timing, and follow-up care. This review outlines the latest evidence on diagnosing and managing pediatric primary spontaneous pneumothorax (PSP). Current research favors a symptom-based diagnostic method, with chest X-rays serving as the primary imaging tool. Routine CT scans are discouraged because they expose children to unnecessary radiation, rarely change initial treatment plans, and fail to reliably predict recurrence based on radiographic blebs. Ultimately, treatment strategies should be customized based on the patient's clinical stability rather than relying solely on the size of the pneumothorax. Observation is a suitable approach for certain stable patients with small to moderate PSP. Conversely, treatments such as needle aspiration, chest tube drainage, or surgery should be utilized only for patients experiencing severe symptoms, continuous air leaks, unsuccessful lung re-expansion, or recurring pneumothorax. When surgical intervention is required, video-assisted thoracoscopic surgery is the favored method, though post-operative recurrence rates are higher in children compared to adults. Current evidence indicates a lack of standardized follow-up procedures for pediatric patients. Therefore, follow-up care should center on the early detection of recurrences, which typically happen within the first year of the initial event. The use of routine computed tomography for follow-up is not recommended. Additionally, patient counseling needs to address smoking and vaping cessation, guidelines for resuming physical activity, postponing air travel until imaging shows complete healing, and avoiding compressed-air diving due to a lifelong recurrence risk. Although recent progress has been made, significant knowledge gaps persist concerning the ideal selection of patients for conservative rather than surgical treatment, risk factors for recurrence, uniform follow-up protocols, and long-term results. To develop evidence-based, child-specific guidelines for diagnosing and treating primary spontaneous pneumothorax, future prospective multicenter pediatric studies are essential.