From the Guidelines
For a small apical pneumothorax, high-flow oxygen therapy at 10 liters per minute is the recommended approach, as it has been shown to result in a four-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation 1. This approach is based on the principle that breathing high concentrations of oxygen reduces the partial pressure of nitrogen in the bloodstream, increasing the rate of nitrogen absorption from the pleural space. The goal of oxygen therapy in this context is to achieve an oxygen saturation of 94–98% if the patient is not at risk of hypercapnic respiratory failure 1. Key considerations for this treatment include:
- Monitoring the patient's oxygen saturation, respiratory rate, and symptoms during therapy
- Positioning the patient upright if tolerated to help localize the air collection apically
- Adjusting oxygen flow rates for patients with underlying lung disease like COPD to prevent carbon dioxide retention
- Limiting conservative management to small, stable pneumothoraces (typically less than 15-20% of the hemithorax) in patients without significant respiratory distress or hemodynamic compromise.
From the Research
Management of Small Apical Pneumothorax
The management of small apical pneumothorax can be approached in several ways, including observation, needle aspiration, and chest tube thoracostomy.
- The choice of management depends on the size of the pneumothorax, the patient's symptoms, and their overall clinical condition 2, 3.
- For small pneumothoraces, observation may be a reasonable approach, especially if the patient is asymptomatic and has no signs of respiratory distress 3.
- Needle aspiration has been shown to be a safe and effective treatment for small pneumothoraces, with a lower risk of complications compared to chest tube thoracostomy 4, 5.
- The use of lung ultrasound (US) has been proposed as a useful tool in the detection of pneumothorax, and may be more sensitive than chest x-ray (CXR) in some cases 3.
Comparison of Needle Aspiration and Chest Tube Thoracostomy
Several studies have compared the efficacy and safety of needle aspiration and chest tube thoracostomy for the management of pneumothorax.
- A study published in the Journal of Thoracic Disease found that needle aspiration was associated with a shorter hospital stay and lower hospitalization rate compared to chest tube drainage 4.
- Another study published in the Annals of Emergency Medicine found that needle aspiration was at least as safe and effective as tube thoracostomy for the management of primary spontaneous pneumothorax, with a lower risk of complications and shorter length of hospital stay 5.
- However, the risk of pneumothorax and chest tube placement associated with computed tomography (CT)-guided transthoracic needle aspiration biopsy (TNAB) of the lung has been reported to be higher in patients with increased lesion depth and smaller lesion size 6.
Considerations for Oxygen Therapy
While the provided studies do not specifically address the best oxygen for small apical pneumothorax, they do highlight the importance of careful patient selection and monitoring when managing pneumothorax.
- Patients with small pneumothoraces who are asymptomatic and have no signs of respiratory distress may not require supplemental oxygen 3.
- However, patients with larger pneumothoraces or those who are experiencing respiratory distress may require supplemental oxygen and close monitoring of their oxygen saturation levels 2, 3.