From the Guidelines
Open pneumothorax requires immediate coverage of the chest wall defect with an occlusive dressing and subsequent chest tube placement to prevent tension pneumothorax, whereas closed pneumothorax may be observed or treated with needle aspiration or chest tube placement depending on size and symptoms. The management of these two conditions differs significantly due to the risk of air entering the pleural space in open pneumothorax, which can lead to life-threatening complications 1.
Key Differences
- Open pneumothorax involves direct communication between the pleural space and the external environment, creating a risk of tension pneumothorax 1.
- Closed pneumothorax, on the other hand, occurs without any communication to the outside world, typically due to spontaneous rupture of blebs, trauma, or iatrogenic causes.
Management
- Open pneumothorax management includes immediate coverage of the chest wall defect with an occlusive dressing (taped on three sides to allow air to escape but not enter) 1.
- Closed pneumothorax may be observed if small or treated with needle aspiration or chest tube placement depending on size and symptoms.
Complications
- The primary concern with open pneumothoraces is the risk of tension developing, which can cause mediastinal shift, decreased venous return, and cardiovascular collapse 1.
- Both types require careful monitoring, pain control, and follow-up imaging to ensure proper lung re-expansion.
From the Research
Definition and Classification of Pneumothorax
- Pneumothorax (PTX) is defined as air in the pleural space and is classified as spontaneous or nonspontaneous (traumatic) 2.
- Traumatic PTX is a common pathology identified in the emergency department 2, 3.
Diagnosis of Pneumothorax
- Traditional diagnosis calls for chest x-ray (CXR) diagnosis, although recent literature supports the efficacy of lung ultrasound (US) and computed tomography (CT) 2, 3.
- Lung US has proven to be a potentially more useful tool in the detection of PTX in the trauma bay compared with CXR 2.
- CT remains the ultimate gold standard, although in the setting of trauma, its utility lies more in confirming the presence and measuring the size of a PTX 2.
Management of Pneumothorax
- Traditional management calls for large-bore tube thoracostomy, although recent literature demonstrates pigtail catheters as equally efficacious alternatives 2, 3.
- In patients with small or occult PTXs, even observation may be reasonable 2, 3.
- The administration of high concentrations of inspired oxygen is an effective method to enhance the rate of resolution of pneumothoraces, particularly when smaller than 30% 4.
- Pneumothoraces in unstable, critically ill patients or in those on mechanical ventilation should be managed with tube thoracostomy 5.
- If there is suspicion for tension pneumothorax, immediate decompression and drainage should be performed 5.