From the Guidelines
For an unresolving pneumothorax with a chest tube already inserted, applying suction after 48 hours for persistent air leak or failure of the pneumothorax to re-expand is recommended, with high volume, low pressure (–10 to –20 cm H2O) suction systems being preferred 1. The management of unresolving pneumothorax involves several key considerations to ensure the best possible outcome for the patient.
Initial Steps
First, it is crucial to ensure the chest tube is functioning properly by checking for kinks, clots, or displacement, and confirming proper suction settings (typically -20 cm H2O) 1. Performing a chest X-ray to verify tube position and assess the remaining pneumothorax is also essential. If the tube is properly positioned but the pneumothorax persists, considering placing an additional chest tube, particularly if the first tube is small-caliber or poorly positioned, may be necessary.
Persistent Air Leaks
For persistent air leaks beyond 5-7 days, surgical intervention may be necessary, typically via video-assisted thoracoscopic surgery (VATS) to identify and repair the air leak 1. Chemical pleurodesis using agents like talc or doxycycline can be considered for patients who are poor surgical candidates 1. Throughout management, ensuring adequate pain control with scheduled acetaminophen, NSAIDs if not contraindicated, and opioids as needed is vital. The persistence of pneumothorax despite chest tube placement often indicates either a mechanical issue with the drainage system or an ongoing air leak from the lung parenchyma that exceeds the drainage capacity of the current tube.
Key Considerations
- The application of suction should be considered after 48 hours for persistent air leak or failure of the pneumothorax to re-expand 1.
- High volume, low pressure suction systems are recommended to avoid complications such as air stealing, hypoxaemia, or the perpetuation of persistent air leaks 1.
- The decision for surgical intervention should be made on an individual basis, considering the patient's overall condition, the presence of underlying lung disease, and the size of the pneumothorax 1.
- Patient choice and the potential benefits and risks of each treatment option should inform the decision-making process 1.
Treatment Options
Some key treatment options for unresolving pneumothorax include:
- Application of thoracic suction
- Converting to a larger-bore chest drain
- Blood patch or chemical pleurodesis
- Endobronchial valves
- Thoracic surgery 1 Each of these options has its own set of indications, benefits, and risks, and the choice of treatment should be tailored to the individual patient's needs and circumstances.
From the Research
Unresolving Pneumothorax with Chest Tube Inserted
- An unresolving pneumothorax with a chest tube inserted can be a challenging condition to manage, and various treatment options are available 2, 3, 4.
- Video-assisted thoracic surgery (VATS) is a minimally invasive technique that can be used to treat pneumothorax, and it has been shown to be effective in reducing recurrence rates and length of hospitalization compared to chest tube drainage 3, 4.
- The evidence suggests that VATS can be an effective alternative to standard chest tube drainage, with reduced ipsilateral recurrence rates and length of hospitalization 3.
- However, the quality of the evidence is generally low, and more well-designed randomized controlled trials are necessary to strengthen the current evidence 3.
- The management of chest tubes after surgery for pneumothorax is not well established, and most of the current knowledge is extrapolated from studies performed on subjects with lung cancer 5.
- Regulated suction may provide some benefit in reducing pneumothorax recurrence after bullectomy and pleurodesis, but more research is needed to determine the optimal management of chest tubes after surgery for pneumothorax 5.
Treatment Options
- VATS is a broadly indicated surgery for pneumothorax, and it is judged to be less invasive, resulting in minimal postoperative pain, short periods of chest tube placement and hospitalization, and early realization of social integration 4.
- Open thoracotomy is also an option, but it may be more invasive and result in longer recovery times 4.
- Chest tube drainage is a common treatment for pneumothorax, but it may be associated with higher recurrence rates and longer hospitalization times compared to VATS 3.