What are the indications for decompressing a pneumothorax in a hemodynamically stable patient?

From the Guidelines

Decompression of a pneumothorax in a hemodynamically stable patient is indicated when the pneumothorax is of sufficient size to intervene, typically 2 cm laterally or apically on CXR, or any size on CT scan which can be safely accessed with radiological support, as stated in the British Thoracic Society guideline for pleural disease 1. The decision to decompress a pneumothorax in a hemodynamically stable patient depends on various factors, including the size of the pneumothorax, the presence of symptoms, and the patient's underlying lung disease.

• The British Thoracic Society guideline for pleural disease recommends that pneumothorax of sufficient size to intervene depends on clinical context but, in general, usually 2 cm laterally or apically on CXR, or any size on CT scan which can be safely accessed with radiological support 1.
• The guideline also states that if the patient is symptomatic, high-risk characteristics are absent, and the pneumothorax is of sufficient size, then intervention is recommended 1.
• In patients with minimal symptoms and small pneumothoraces, observation alone with supplemental oxygen may be appropriate as the air can be reabsorbed naturally over time 1.
• Additional indications for decompression include patients requiring positive pressure ventilation, those planning air travel or going to high altitude areas, and patients with underlying lung disease who may not tolerate even a small pneumothorax. The procedure typically involves needle aspiration or placement of a small-bore chest tube, and the choice of procedure depends on the patient's clinical context and the availability of local resources.
• The British Thoracic Society guideline recommends that the choice of procedure should take into account patient preference and local availability 1.
• The guideline also states that regular review and follow-up are essential to ensure that the pneumothorax is resolving and that the patient is not developing any complications 1.

From the Research

Indications for Decompressing a Pneumothorax

The decision to decompress a pneumothorax in a hemodynamically stable patient depends on several factors, including the size of the pneumothorax, symptoms, and underlying lung disease.

• A study published in 2016 2 reported a case of a large pneumothorax in a blunt chest trauma patient that resolved spontaneously without a chest drain, suggesting that conservative management can be safe and effective for small pneumothorax in stable patients.
• Another study from 1988 3 demonstrated that small-caliber catheters can effectively decompress pneumothoraxes, and they can be inserted expeditiously by radiologists in the radiology department.
• The use of a device for the management of tension pneumothorax has been shown to be effective in both prehospital and in-hospital settings by physician and EMT-Paramedic personnel 4.

Size and Symptoms of Pneumothorax

• A pneumothorax of more than 30% of the hemithorax may require decompression, even in a hemodynamically stable patient 2.
• Symptomatic pneumothorax, such as those causing chest pain or shortness of breath, may also require decompression 3.
• The presence of underlying lung disease, such as chronic obstructive lung disease (COPD), may increase the risk of tension pneumothorax and require more aggressive management 5.

Methods of Decompression

• Needle aspiration, catheter placement, or tube thoracostomy are common methods of decompressing a pneumothorax 3, 4, 6.
• The choice of method depends on the size and symptoms of the pneumothorax, as well as the patient's overall condition.
• A study from 2010 6 found that the length of the catheter used for needle thoracostomy can affect the success of the procedure, with longer catheters being more effective.