From the Guidelines
When a pneumothorax is not resolving despite chest tube placement, thoracic surgery is often the treatment of choice for ongoing air leak. This approach is supported by the British Thoracic Society guideline for pleural disease, which suggests that thoracic surgery has the potential to reduce the risk of recurrence and is often considered for patients with ongoing air leak or recurrent pneumothorax 1.
Initial Steps
Before considering surgical intervention, it is essential to ensure the chest tube is functioning properly by checking for kinking, clogging, or malposition using chest imaging. The tube may need repositioning or replacement with a larger bore tube (24-32 French). Adding suction at -10 to -20 cm H2O if not already applied can also help resolve the pneumothorax.
Management of Persistent Air Leaks
Persistent air leaks may indicate a bronchopleural fistula, which might require surgical intervention if it persists beyond 5-7 days. Chemical pleurodesis using agents like talc or doxycycline can help seal persistent leaks, as mentioned in the guideline 1. For patients with underlying lung disease, optimizing management of conditions like COPD or asthma is essential. Endobronchial valves may be considered in select cases to reduce air leaks.
Surgical Options
Surgical options include video-assisted thoracoscopic surgery (VATS) or thoracotomy with mechanical pleurodesis, stapling of blebs, or pleurectomy if conservative measures fail. The British Thoracic Society guideline highlights the potential benefits of thoracic surgery in reducing the risk of recurrence and managing ongoing air leaks 1. Throughout management, ensuring adequate pain control and pulmonary toilet is crucial to prevent complications like atelectasis or pneumonia. The underlying cause of the persistent pneumothorax should guide the specific approach to management.
From the Research
Pneumothorax Not Resolving Despite Chest Tube
- A pneumothorax that does not resolve despite chest tube placement can be a challenging condition to manage, and the approach may vary depending on the underlying cause and patient factors 2, 3.
- In patients with spontaneous pneumothorax, definitive measures to prevent recurrence, such as pleurodesis, may be recommended after the first recurrence 2.
- For traumatic pneumothoraces, the traditional approach of large-bore tube thoracostomy is being challenged by recent literature supporting the use of smaller catheters or observation for small or occult pneumothoraces 4.
- In patients with persistent air leak or whose lungs do not re-expand, a thoracic surgery consultation is recommended, and other options such as bronchoscopic interventions or autologous blood patch may be considered 3.
Management Options
- Small-bore chest tube placement is currently recommended as the first line management of pneumothorax 3.
- Thoracic ultrasound has emerged as a useful tool in the detection of pneumothorax and may become the new gold standard for diagnosing traumatic pneumothorax 4.
- Computed tomography remains the ultimate gold standard for diagnosis, although its utility lies more in confirming the presence and measuring the size of a pneumothorax 4.
- Prophylactic antibiotics may be beneficial in reducing the incidence of infectious complications in patients undergoing tube thoracostomy for chest trauma 5, 6.
Considerations
- Patient stability and the size of the pneumothorax should be taken into account when deciding on the management approach 2, 3.
- The use of prophylactic antibiotics should be administered selectively, considering the case severity and risk factors 6.
- A multidisciplinary approach, including thoracic surgery consultation, may be necessary for patients with complex or persistent pneumothoraces 3.