From the Guidelines
Non-invasive positive pressure ventilation (NIPPV) should not be used in patients with pneumothorax as it can worsen the condition and lead to potentially life-threatening complications. When positive pressure is applied to the airways of a patient with pneumothorax, it can force more air into the pleural space, causing the pneumothorax to expand. This expansion increases pressure on the lung and can lead to tension pneumothorax, which is a medical emergency that can cause cardiovascular collapse due to decreased venous return to the heart.
Key Considerations
- The use of NIPPV in patients with pneumothorax is generally contraindicated due to the risk of worsening the pneumothorax and causing tension pneumothorax 1.
- Instead of NIPPV, patients with pneumothorax typically require chest tube placement to evacuate the air from the pleural space and allow the lung to re-expand.
- Oxygen therapy via a non-rebreather mask or nasal cannula may be used to support oxygenation without applying positive pressure.
- If respiratory support is absolutely necessary in a patient with pneumothorax, it should only be provided after chest tube placement and under careful monitoring by experienced clinicians, as suggested by guidelines and studies 1.
Clinical Decision Making
The decision to use NIPPV in a patient with pneumothorax should be made with caution and only after careful consideration of the potential risks and benefits. The underlying pneumothorax must be addressed first before considering any form of positive pressure ventilation. In general, withholding NIPPV from patients with pneumothorax is acceptable management until the pneumothorax is resolved, as recommended by the most recent and highest quality study 1.
From the Research
Use of Non-Invasive Positive Pressure Ventilation (NIPPV) in Pneumothorax
- The use of NIPPV in patients with pneumothorax is a complex issue, as positive pressure ventilation itself can predispose to both initial and recurrent pneumothoraces 2.
- There is a lack of clear guidance on the management of pneumothorax in chronically ventilated patients, and generally accepted pneumothorax management strategies may not be possible in this population 2.
- A case series suggests that definitive treatment of the initial pneumothorax may be necessary to prevent reoccurrence in patients requiring chronic noninvasive mechanical ventilation 2.
Management of Pneumothorax
- The management of pneumothorax typically involves a three-step strategy, including the recovery of acute respiratory dysfunction, the avoidance of respiratory dysfunction and subsequent complications, and the prevention of recurrence 3.
- The use of chest tube insertion or simple aspiration may be necessary, depending on the size and symptoms of the pneumothorax, as well as the presence of tension pneumothorax 3, 4.
- In patients with pneumothorax in the ICU, management with a tube thoracostomy is recommended if they are symptomatic or on mechanical ventilation 4.
Risks and Complications
- Pneumothorax is a common complication in ICU patients, particularly those with underlying lung disease who require positive pressure ventilation 4.
- Barotrauma and iatrogenesis are common causes of pneumothorax in critically ill patients, and a timely diagnosis is critical to prevent tension physiology 4.
- The use of ultrasound guidance and chest X-rays can help prevent and diagnose pneumothorax, respectively 5.