From the Guidelines
Management of secondary spontaneous pneumothorax typically requires chest tube insertion for air evacuation, especially for large pneumothoraces (>2-3 cm) or in symptomatic patients, with suction applied after 48 hours for persistent air leak or failure of a pneumothorax to re-expand, as recommended by the BTS guidelines 1. The chest tube should be connected to a water seal or suction system to facilitate lung re-expansion, with high volume, low pressure (–10 to –20 cm H2O) suction systems recommended for patients requiring suction 1. Key considerations for chest tube management include:
- A bubbling chest tube should never be clamped, and a chest tube which is not bubbling should not usually be clamped, unless under the supervision of a respiratory physician or thoracic surgeon 1.
- If a patient with a clamped drain becomes breathless or develops subcutaneous emphysema, the drain must be immediately unclamped and medical advice sought 1.
- Before removal, the tube should be placed on water seal (without suction) for several hours to confirm the absence of air leaks.
- A chest tube can be removed when there is no air leak for 24-48 hours, the lung is fully expanded on chest X-ray, and any underlying condition causing the pneumothorax has been addressed. Additional management includes treating the underlying lung disease (such as COPD, interstitial lung disease, or cystic fibrosis), providing adequate pain control, and considering pleurodesis for recurrent cases, with surgical options like video-assisted thoracoscopic surgery (VATS) may be necessary for persistent air leaks or recurrent pneumothoraces. Following chest tube removal, a follow-up chest X-ray is recommended to ensure the lung remains expanded, and patients should avoid air travel and scuba diving for at least two weeks.
From the Research
Management of Secondary Spontaneous Pneumothorax
- Secondary spontaneous pneumothorax should be treated with chest tube drainage followed by pleurodesis after the first episode to minimize any risk of recurrence 2.
- The management of pneumothorax has traditionally been tube thoracostomy and -20 cm H2O suction 3.
- Small-bore chest tubes (≤14F) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients and pleural effusions in general 4.
Removal of Chest Tube
- The optimal timing for tube removal is still a matter of controversy 4.
- Tubes were discontinued at 48 hours if there were no pneumothoraces and no air leaks 3.
- A drain-clamping test before tube withdrawal is generally not advocated 4.
- Digital drainage systems can facilitate informed and prudent decision-making in the removal of chest tubes 4.
Treatment Options
- Small-bore pleural catheter and manual aspiration might be similarly effective as chest tube drainage in terms of immediate lung re-expansion 5.
- A serial-steps approach with a single system (small-calibre catheter/Heimlich valve) can be effective in the management of primary spontaneous pneumothorax 6.
- Pleurodesis can be achieved by medical (e.g. talc) or surgical (video-assisted thoracic surgery) methods 2.