What is the difference in treatment and management between pneumothorax and pneumomediastinum?

From the Guidelines

The treatment and management of pneumothorax and pneumomediastinum differ significantly based on their distinct pathophysiology and clinical implications, with pneumothorax typically requiring more aggressive intervention, as outlined in the British Thoracic Society guideline for pleural disease 1. The management of pneumothorax involves a range of strategies, including conservative management, needle aspiration, ambulatory management, chemical pleurodesis, and thoracic surgery, with the choice of treatment depending on the size and severity of the pneumothorax, as well as the patient's overall health and medical history 1. Some key points to consider in the management of pneumothorax include:

• Small, stable pneumothoraces (<20% lung volume) may be managed conservatively with observation, oxygen supplementation, and serial chest X-rays 1
• Larger pneumothoraces often require needle aspiration or chest tube placement (typically 16-28 French tube inserted at the 4th-5th intercostal space, mid-axillary line) connected to underwater seal drainage 1
• Tension pneumothorax represents a medical emergency requiring immediate needle decompression with a 14-16 gauge needle at the 2nd intercostal space, mid-clavicular line, followed by chest tube placement 1 In contrast, pneumomediastinum (air in the mediastinum) is typically managed conservatively with rest, oxygen therapy, pain control with NSAIDs or acetaminophen, and avoidance of activities that increase intrathoracic pressure, with most cases resolving spontaneously within 3-14 days 1. The key difference in management between pneumothorax and pneumomediastinum is the need for more aggressive intervention in pneumothorax, including hospitalization and procedural intervention, whereas pneumomediastinum can often be managed as an outpatient with conservative treatment. Both conditions benefit from oxygen therapy (2-4 L/min via nasal cannula) which accelerates air reabsorption, but the underlying mechanisms of the two conditions - pneumothorax directly compromising lung expansion and ventilation, while pneumomediastinum typically representing a self-limiting air leak that rarely causes significant cardiorespiratory compromise - dictate the differing management approaches 1.

From the Research

Treatment and Management of Pneumothorax

• The treatment for pneumothorax varies from invasive chest tube drainage to conservative management with bed rest 2.
• 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%, thereby reducing morbidity and duration of hospitalization and avoiding invasive drainage procedures 2.
• Lung ultrasound (US) has proven to be a potentially more useful tool in the detection of pneumothorax in the trauma bay compared with chest x-ray (CXR), and has the potential to become the new gold standard for diagnosing traumatic pneumothorax 3.
• The traditional mantra calling for large-bore chest tubes as first-line approaches to traumatic pneumothorax is challenged by recent literature demonstrating pigtail catheters as equally efficacious alternatives 3.
• In patients with small or occult pneumothoraces, even observation may be reasonable 3.

Treatment and Management of Pneumomediastinum

• Pneumomediastinum is the manifestation of a variety of causes including those that are benign and some resulting in severe morbidity and even mortality 4.
• The workup and management of patients diagnosed with pneumomediastinum is reviewed, but specific treatment options are not provided in the available evidence.
• Pneumomediastinum can be a complication of oxygen therapy, and simple actions can be taken to prevent its reproduction 5.
• The adoption of lung-protective ventilation strategies has played a significant role in reducing the occurrence of barotrauma, such as pneumomediastinum, in acute respiratory distress syndrome (ARDS) patients 6.

Comparison of Treatment and Management

• The treatment and management of pneumothorax and pneumomediastinum differ, with pneumothorax having more established treatment options, including chest tube drainage and conservative management with oxygen therapy 2, 3.
• Pneumomediastinum treatment options are not as well-established, but the adoption of lung-protective ventilation strategies can help reduce its occurrence in ARDS patients 6.
• Both conditions can be challenging to manage, and further research is imperative to enhance the risk assessment and institute more effective prevention and treatment measures 6.