Paeds · respiratory-sleep-and-airway
Pneumothorax and air-leak syndromes
Also known as Paediatric pneumothorax · Tension pneumothorax in children · Air-leak syndrome · Pneumomediastinum · Pulmonary interstitial emphysema · Pneumopericardium · Primary spontaneous pneumothorax
A fellowship approach to pneumothorax and the wider family of air-leak syndromes in children: recognise tension physiology and decompress before imaging, understand the Macklin route by which alveolar air tracks to the pleura, mediastinum, interstitium and pericardium, separate primary spontaneous from secondary, traumatic and neonatal disease, size the leak, and match management from observation and oxygen through needle decompression, aspiration and chest drainage to surgery for persistent or recurrent leaks.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- Hypotension, tachycardia, distended neck veins and tracheal deviation with unilateral absent breath sounds — tension pneumothorax, decompress before imaging
- Sudden deterioration, rising oxygen requirement or a swing in the endotracheal tube trace in a ventilated child or neonate
- Sudden cardiovascular collapse with muffled heart sounds in a ventilated neonate — consider pneumopericardium
- Acute pleuritic chest pain and breathlessness in a tall thin adolescent
- Pneumothorax in a child with cystic fibrosis, asthma, connective-tissue disease or known lung disease
- Rapidly expanding surgical emphysema of the neck and chest wall
- Bilateral pneumothoraces or a large air leak in a small infant with little respiratory reserve
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Acute and emergency assessment
- Respiratory Medicine
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
- Renewed curriculum for first-year trainees from 2027 — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 15: Essential general paediatrics
- Respiratory 13–15
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- 1. Emergency and acute care
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing
- 11. Respiratory
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- Video
- General Pediatrics Content Outline — Emergency and critical care
- General Pediatrics Content Outline — Respiratory disorders
- General Pediatrics EPA 7: Recognizing a Severely Ill Patient, Providing Initial Management, and Mobilizing Resources Needed for Continued Care
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Systems-Based Practice 1: Patient Safety
- Medical Knowledge 2: Emergency and critical care
- Medical Expert
- Pediatrics: Foundations EPA #1 — Recognizing deteriorating and/or critically ill patients and initiating stabilization and management
- Pediatrics: Foundations EPA #8 — Communicating assessment findings and management plans to patients and/or families
- Pediatrics: Respiratory (5–10%)
A previously well 16-year-old, tall and slim, drops to the floor at school with sudden left-sided chest pain and breathlessness; his left chest is quiet and hyper-resonant. Two cots away in the neonatal unit, a ventilated 27-weeker suddenly desaturates and his blood pressure falls, the left chest transilluminating like a lantern. Both children have air in the wrong place, but the physiology, the risk, and the drain you reach for differ — and reading those differences is what this page teaches. [5] [7]
This hub owns the air-leak logic: how air escapes, where it goes, when it is under tension, and how to size and drain it. Disease-specific pages carry the underlying conditions — acute severe asthma, bronchiolitis, and the broader respiratory distress and failure framework into which the collapsing child fits. [2] [8]
Ask about tension first — decompress before imaging · Identify the compartment: pleura, mediastinum, interstitium, pericardium · Radiograph and size the leak once stable · Lung disease? Primary versus secondary changes the plan · Escalate: observe, aspirate, drain, operate · Admit secondary, neonatal and large leaks · Keep oxygen running — it speeds resorption. [2] [3] [5]
Overview & Definition
Watch normal breathing and the two pleural layers glide against each other on a thin film of fluid, held together by a slightly negative pressure that keeps the lung expanded. A pneumothorax breaks that seal: air enters the pleural space, the negative pressure is lost, and the elastic lung recoils inward and collapses away from the chest wall. The child feels it as sudden pleuritic pain and breathlessness. [3] [11]
Pneumothorax is the best-known member of a wider family of air-leak syndromes, all of which begin with air escaping the alveolus or airway into a space it should never reach. That air can settle in the pleura, dissect into the mediastinum as pneumomediastinum, remain trapped within the lung tissue as pulmonary interstitial emphysema, ring the heart as pneumopericardium, or push out into the neck and chest wall as surgical emphysema. The compartment it reaches determines the picture and the danger. [7] [12]
The single most important distinction is not where the air is but whether it is under tension. A simple pneumothorax is a stable collection that the child tolerates; a tension pneumothorax is a progressively enlarging collection that shifts the mediastinum, obstructs venous return, and kills if not decompressed. Tension is recognised at the bedside and treated immediately, and this urgency frames everything else on the page. [2] [7]
References12ShowHide
- [1]Brown SGA Conservative versus Interventional Treatment for Spontaneous Pneumothorax. N Engl J Med, 2020.PMID 31995686
- [2]Roberts ME British Thoracic Society Guideline for pleural disease. Thorax, 2023.PMID 37553157
- [3]MacDuff A Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax, 2010.PMID 20696690
- [4]Hallifax RJ Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial. Lancet, 2020.PMID 32622394
- [5]Lieu N Update in management of paediatric primary spontaneous pneumothorax. Paediatr Respir Rev, 2022.PMID 34511373
- [6]Stewart S Management of Primary Spontaneous Pneumothorax in Children: A Single Institution Protocol Analysis. J Pediatr Surg, 2023.PMID 36803908
- [7]Jhaveri V Pneumothorax in a term newborn. J Perinatol, 2024.PMID 38409329
- [8]Flume PA Cystic fibrosis pulmonary guidelines: pulmonary complications: hemoptysis and pneumothorax. Am J Respir Crit Care Med, 2010.PMID 20675678
- [9]Lichtenstein DA Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest, 2008.PMID 18403664
- [10]Terboven T Chest wall thickness and depth to vital structures in paediatric patients - implications for prehospital needle decompression of tension pneumothorax. Scand J Trauma Resusc Emerg Med, 2019.PMID 30992028
- [11]Mendogni P Epidemiology and management of primary spontaneous pneumothorax: a systematic review. Interact Cardiovasc Thorac Surg, 2020.PMID 31858124
- [12]Rose SJ Pulmonary interstitial emphysema. Arch Dis Child, 1985.PMID 3885872