Can a patient with a pneumothorax be intubated and placed on a ventilator (ventilator)

Management of Intubation in Patients with Pneumothorax

In patients with a pneumothorax, an intercostal drain should be inserted before proceeding with intubation and mechanical ventilation to prevent worsening of the pneumothorax and potential tension pneumothorax development. 1

Rationale and Approach

The presence of a pneumothorax presents significant challenges when considering intubation and mechanical ventilation due to the risk of converting a simple pneumothorax into a tension pneumothorax, which can be life-threatening.

Key Considerations Before Intubation

1. Chest Drain Placement:

   • Insert an intercostal drain before initiating positive pressure ventilation
   • This is a clear recommendation from thoracic guidelines 1
   • While NIV has been used in patients with undrained pneumothorax without apparent worsening, this is not recommended for invasive ventilation

2. Risk Assessment:

   • Positive pressure ventilation significantly increases the risk of expanding a pneumothorax
   • The higher the ventilatory pressures, the greater the risk of pneumothorax expansion 2
   • Tension pneumothorax can develop rapidly after intubation, leading to hemodynamic collapse

3. Location for Procedure:

   • Intubation of patients with pneumothorax should ideally occur in a high-dependency setting (ICU/HDU)
   • This ensures immediate access to chest tube placement if the pneumothorax worsens 1

Management Algorithm

1. Confirm pneumothorax diagnosis

   • Chest X-ray or point-of-care ultrasound
   • Assess size and whether there is mediastinal shift

2. Insert intercostal drain before intubation

   • Place chest tube in the 4th-5th intercostal space, mid-axillary line
   • Confirm proper placement with chest X-ray if time permits

3. Proceed with intubation after chest drain placement

   • Use rapid sequence induction to minimize positive pressure during bag-mask ventilation
   • Consider using smaller tidal volumes (6-8 ml/kg) initially
   • Apply lower PEEP settings initially (≤5 cmH2O) if possible

4. Post-intubation monitoring

   • Watch for signs of worsening pneumothorax despite chest tube
   • Monitor for decreased oxygen saturation, increased peak airway pressures, hemodynamic instability
   • Assess chest tube output and function

Special Considerations

• Tension Pneumothorax: If signs of tension pneumothorax develop during intubation (before chest tube placement), perform immediate needle decompression followed by chest tube placement 2

• Small, Stable Pneumothoraces: While some literature suggests observation of small pneumothoraces in intubated COVID-19 patients 3 or preterm infants 4, 5, this approach should not be applied to the general population requiring intubation

• Unavoidable Emergency Intubation: If intubation cannot be delayed due to critical hypoxemia:

  • Be prepared for immediate chest tube placement post-intubation
  • Use lower tidal volumes and ventilatory pressures
  • Avoid high PEEP settings initially 6

Potential Complications

• Conversion of simple pneumothorax to tension pneumothorax
• Hemodynamic collapse from positive pressure effects on venous return
• Expansion of pneumothorax despite chest tube (if tube is malpositioned or occluded)
• Contralateral pneumothorax development

Conclusion

The evidence clearly supports chest tube placement before intubation in patients with pneumothorax. While there are case reports of successful expectant management in specific populations, the safest approach in general practice is to secure the pneumothorax with a chest drain before applying positive pressure ventilation.