Treatment of Pneumothorax
The treatment of pneumothorax should be tailored based on the type of pneumothorax, patient symptoms, and pneumothorax size, with conservative management being appropriate for minimally symptomatic primary spontaneous pneumothorax regardless of size. 1
Classification and Initial Assessment
- Primary Spontaneous Pneumothorax (PSP): Occurs without clinically apparent underlying lung abnormalities
- Secondary Spontaneous Pneumothorax (SSP): Occurs with clinically apparent underlying lung disease
- Traumatic Pneumothorax: Results from trauma or iatrogenic causes
Key Assessment Parameters:
- Size of pneumothorax (small: <3 cm apex-to-cupola distance; large: ≥3 cm) 1
- Presence of symptoms (pain, breathlessness)
- Clinical stability (respiratory rate <24/min, heart rate 60-120/min, normal BP, O₂ saturation >90%) 1
- Underlying lung disease
Treatment Algorithm
1. Minimally Symptomatic or Asymptomatic Primary Spontaneous Pneumothorax
- Conservative management is appropriate regardless of size 1
- High-flow oxygen (10-15 L/min via reservoir mask) to increase reabsorption rate four-fold 2
- Clear discharge instructions with follow-up within 12-48 hours 2
- Return if breathlessness develops
2. Symptomatic Primary Spontaneous Pneumothorax
- Simple aspiration as first-line treatment for symptomatic or large pneumothoraces (>2 cm or >50%) 2
- Success rates: 59-83% overall
- Higher success in smaller pneumothoraces (<50%: 77% vs >50%: 62%)
- Higher success in younger patients (<50 years: 70-81% vs >50 years: 19-31%)
- If aspiration fails, proceed to chest tube drainage
3. Secondary Spontaneous Pneumothorax
- Chest tube drainage (small-bore catheter ≤14F or moderate-sized tube 16F-22F) 1
- Can be attached to either:
- Heimlich valve (one-way valve)
- Water seal device (with or without suction)
- Apply suction if lung fails to re-expand quickly
4. Clinically Unstable Patients
- Immediate chest tube insertion (16F-22F standard chest tube) 1
- Consider larger tubes (24F-28F) if:
- Bronchopleural fistula with large air leak is anticipated
- Patient requires positive-pressure ventilation
5. Traumatic Pneumothorax
- Chest tube insertion rather than simple aspiration 2, 3
- For pneumothorax >20% of thoracic volume on chest X-ray or >35 mm on CT 4
- Smaller traumatic pneumothoraces may be observed with close monitoring 4
6. Tension Pneumothorax
- Immediate needle decompression followed by chest tube placement 2
Management of Persistent Air Leak or Recurrence
- Consider surgical referral if air leak persists beyond 5-7 days 2
- Surgical options for recurrent pneumothorax or persistent air leak:
- For patients not fit for surgery, consider autologous blood pleurodesis or endobronchial therapies 1
Follow-up and Prevention
- Follow-up with respiratory physician to ensure complete resolution 2
- Advise against air travel for at least 7 days after radiological confirmation of complete resolution 2
- Counsel regarding smoking cessation if applicable 2
- Consider elective surgery for:
Important Considerations
- Any pneumothorax with breathlessness requires intervention regardless of size 2
- Patients managed conservatively need clear instructions about when to return 2
- Hospital admission should be considered if the patient lives far from emergency services 2
- Monitor for signs of clinical deterioration (increasing dyspnea, tachycardia, hypotension) 2
The most recent evidence supports a more conservative approach to pneumothorax management, with simple aspiration or even observation being appropriate for many cases of primary spontaneous pneumothorax, while more aggressive intervention with chest tubes remains necessary for secondary, traumatic, or unstable presentations.