Is Non-Invasive Ventilation (NIV) recommended for patients with pneumothorax?

Non-Invasive Ventilation in Pneumothorax

In patients with pneumothorax, an intercostal drain should be inserted before commencing non-invasive ventilation (NIV). 1

Contraindications and Risk Assessment

Pneumothorax is listed as a contraindication to NIV in clinical guidelines, but with important qualifications:

• Undrained pneumothorax is considered a contraindication to NIV 1
• Although NIV has been used successfully in the presence of pneumothorax, the standard of care is to insert an intercostal drain first 1
• The risk of pneumothorax expansion or barotrauma is significant when applying positive pressure to a patient with an existing pneumothorax 2

Management Algorithm

1. Identify pneumothorax

   • Confirm diagnosis with appropriate imaging (chest X-ray, ultrasound, or CT)
   • Assess size and clinical impact of pneumothorax

2. Intercostal drain placement

   • Insert chest tube before initiating NIV 1
   • Ensure proper positioning and functioning of the drain
   • Confirm resolution or adequate drainage of pneumothorax

3. NIV initiation after drainage

   • Once pneumothorax is adequately drained, NIV can be initiated if indicated
   • Start with lower pressure settings to minimize risk of air leak or expansion
   • Gradually titrate to effective settings

4. Monitoring during NIV

   • Patients with chest drains receiving NIV should be monitored in an ICU setting 1
   • Clinical assessment should include:
     • Chest wall movement
     • Coordination with ventilator
     • Respiratory rate and effort
     • Patient comfort
     • Mental state
   • Monitor for signs of worsening pneumothorax or new air leak

Special Considerations

Chronic NIV Users

Patients requiring chronic NIV are at higher risk for both initial and recurrent pneumothoraces 3. For these patients:

• Consider definitive treatment of the initial pneumothorax (e.g., pleurodesis) to prevent recurrence
• More careful monitoring is required when resuming NIV after pneumothorax

Chest Trauma Patients

In patients with chest wall trauma:

• CPAP can be used for hypoxia despite adequate regional anesthesia and high-flow oxygen 1
• NIV should not be used routinely in chest trauma 1
• Due to pneumothorax risk, these patients should be monitored in ICU when receiving positive pressure ventilation 1

Pitfalls and Caveats

• Failure to recognize pneumothorax: Always assess for pneumothorax before initiating NIV in patients with respiratory distress
• Inadequate drainage: Ensure chest tube is functioning properly before starting NIV
• Inappropriate monitoring: Patients with drained pneumothorax on NIV should be monitored in high-acuity settings (ICU/HDU)
• Excessive pressure: Using high pressures may worsen air leaks; start with lower settings and titrate as needed
• Delayed recognition of complications: Monitor for signs of worsening pneumothorax or subcutaneous emphysema 4

NIV can be used despite contraindications like pneumothorax if it is considered the "ceiling" of treatment (when invasive ventilation is not appropriate), but risks and benefits must be carefully weighed 1.