From the Guidelines
Management of pneumothorax after chest tube placement should prioritize a conservative approach, with suction applied only after 48 hours for persistent air leak or failure of lung re-expansion, as recommended by the most recent guidelines 1. The goal of management is to promote lung re-expansion while minimizing complications.
- Key considerations include:
- Initial management with water seal and no suction, unless there is a large air leak or the patient is clinically unstable
- Application of suction (typically -10 to -20 cm H2O) after 48 hours if there is a persistent air leak or failure of lung re-expansion
- Use of high volume, low pressure suction systems to minimize the risk of air stealing, hypoxemia, or perpetuation of air leaks
- Daily chest X-rays to assess lung re-expansion and tube position
- Pain management with scheduled acetaminophen and as-needed opioids
- Removal of the chest tube when the lung is fully expanded, air leak has resolved for 24-48 hours, and drainage is minimal (less than 150 mL/day) According to the British Thoracic Society guideline for pleural disease 1, the optimal management of patients with ongoing air leak involves several treatment options, including application of thoracic suction, converting to larger-bore chest drain, blood patch or chemical pleurodesis, endobronchial valves, or thoracic surgery.
- However, the guideline emphasizes the importance of individualized management, taking into account the patient's underlying condition, size of the pneumothorax, and presence of air leak. It is essential to prioritize the patient's clinical stability and adjust the management approach accordingly, as recommended by the American College of Chest Physicians Delphi consensus statement 1.
- The management approach should be tailored to the individual patient's needs, with a focus on minimizing complications and promoting optimal outcomes.
From the Research
Pneumothorax Management
- 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, with findings including dyspnea, chest pain, tachypnea, and absent breath sounds on lung auscultation 3.
Diagnosis
- Traditional diagnosis of PTX is done using chest x-ray (CXR), but recent literature supports the efficacy of lung ultrasound (US) as a potentially more useful tool in detection 2.
- Computed tomography remains the ultimate gold standard for diagnosing PTX, although its utility lies more in confirming the presence and measuring the size of a PTX 2.
- Portable ultrasonography has provided a way to rapidly diagnose pneumothorax, with a higher sensitivity than plain film 3.
Management
- Traditional management of traumatic PTX calls for large-bore tube thoracostomy, but recent literature demonstrates pigtail catheters as equally efficacious alternatives 2.
- In patients with small or occult PTXs, even observation may be reasonable 2, 3.
- The implementation of a 35 mm guideline for PTX management has been shown to decrease unnecessary tube thoracostomy in hemodynamically normal patients without evidence of hemothorax 4.
- Modern management of traumatic PTX is shifting toward use of US for diagnosis and more conservative management practices, such as smaller catheters or observation, which can reduce length of stay, development of complications, and pain in the trauma patient 2.
Chest Tube Placement
- Chest tube placement is a common treatment for PTX, but recent studies suggest that many patients can be managed conservatively via observation, or with a smaller thoracostomy such as a percutaneous pigtail catheter rather than a larger chest tube 3.
- The use of smaller catheters, such as pigtail catheters, has been shown to be equally efficacious as large-bore chest tubes in the management of traumatic PTX 2.