In addition to encouraging smoking cessation, what is the most appropriate next step in managing a patient with a resolved pneumothorax after chest tube removal?

From the Guidelines

The most appropriate next step in managing this patient's condition is to remove the tube, observe overnight, and perform pleurodesis if pneumothorax occurs. Given the patient's occupation as a flight attendant and history of smoking, it is crucial to consider the risk of recurrence and the potential need for definitive treatment. According to the British Thoracic Society guideline for pleural disease 1, video-assisted thoracoscopy access can be considered for surgical pleurodesis in the general management of pneumothorax in adults, and thoracotomy access and surgical pleurodesis should be considered for the lowest level of recurrence risk required for specific occupations.

The patient should be advised to avoid air travel, scuba diving, and strenuous physical activities for approximately 2-4 weeks to prevent recurrence, as recommended by the cystic fibrosis pulmonary guidelines 1. They should also be educated about symptoms of recurrent pneumothorax, including sudden chest pain and shortness of breath, with instructions to seek immediate medical attention if these occur.

Key considerations in this patient's management include:

• The patient's occupation as a flight attendant, which may increase the risk of recurrence
• The patient's history of smoking, which may contribute to underlying lung disease
• The presence of small blebs, which may increase the risk of recurrence
• The need for definitive treatment, such as pleurodesis or surgical intervention, to prevent future episodes.

Overall, the goal of management is to prevent recurrence, minimize morbidity and mortality, and improve quality of life. By removing the tube, observing overnight, and performing pleurodesis if pneumothorax occurs, we can achieve these goals while also considering the patient's individual needs and risk factors.

From the Research

Management of Resolved Pneumothorax

The patient in question has a resolved pneumothorax after chest tube removal. In addition to encouraging smoking cessation, as supported by 2, the most appropriate next step in managing this patient's condition is to consider the risk of recurrence and the need for further intervention.

Considerations for Next Steps

• The patient has a history of smoking, which is a significant risk factor for pneumothorax recurrence, as noted in 3 and 4.
• The patient has had a significant pneumothorax (50% right side) with small bullae, which increases the risk of recurrence.
• The chest tube was removed, and the lung has completely expanded, but the risk of recurrence remains.

Options for Next Steps

• Remove tube, discharge, and perform procedure if pneumothorax occurs: This option is reasonable, as the patient is stable, and the pneumothorax has resolved. However, it requires close follow-up to monitor for recurrence, as supported by 3.
• Admit to hospital and perform procedure: This option may be more appropriate if the patient has a high risk of recurrence or if there are concerns about the patient's ability to seek medical attention promptly if symptoms recur.
• Add Heimlich valve, follow up in two days, and perform procedure: This option is not typically recommended for routine management of pneumothorax, as supported by 3 and 5.

Recommendation

Based on the evidence, the most appropriate next step in managing this patient's condition is to remove the tube, observe overnight, and perform a procedure if pneumothorax occurs, as this approach balances the need for monitoring with the risk of recurrence, as supported by 3 and 5.