What is the management of pneumothorax (collapsed lung)?

Management of Pneumothorax

The management of pneumothorax should be tailored based on the type of pneumothorax, patient symptoms, and size, with observation being appropriate for small, minimally symptomatic pneumothoraces and active intervention required for any pneumothorax with significant breathlessness regardless of size. 1

Initial Assessment and Classification

Types of Pneumothorax

• Primary spontaneous pneumothorax (PSP): Occurs without apparent cause in absence of significant lung disease
• Secondary spontaneous pneumothorax (SSP): Occurs in presence of existing lung pathology (e.g., COPD, cystic fibrosis)
• Traumatic pneumothorax: Results from trauma or iatrogenic causes (e.g., biopsy)
• Tension pneumothorax: Life-threatening emergency when intrapleural pressure exceeds atmospheric pressure throughout respiratory cycle 2, 1

Diagnostic Approach

• Chest radiograph (PA view): Initial imaging study of choice
• Additional views: Consider lateral or lateral decubitus radiographs when PA findings are unclear
• CT scanning: Most accurate but only needed for complex cases (differentiating pneumothorax from bullous disease, suspected aberrant tube placement)
• Lung ultrasound: Increasingly recognized as useful diagnostic tool, potentially more sensitive than CXR for traumatic pneumothorax 1, 3

Size Classification

• Small pneumothorax: Visible rim of <2 cm between lung margin and chest wall
• Large pneumothorax: ≥3 cm apex-to-cupola distance 1

Management Algorithm

1. Tension Pneumothorax

• Immediate action: Insert cannula of adequate length into second intercostal space in mid-clavicular line
• Follow-up: Leave cannula in place until functioning intercostal tube can be positioned
• Warning signs: Rapid deterioration, cyanosis, sweating, tachycardia, hypotension 2, 4

2. Small Pneumothorax with Minimal/No Symptoms

• First-line: Observation with high-flow oxygen (10 L/min) to increase reabsorption rate
• Caution: Use oxygen with care in COPD patients
• Follow-up: Chest radiograph after 2 weeks to confirm resolution
• Discharge criteria: Patient lives within 30 minutes of hospital and has adequate home support 2, 1

3. Symptomatic or Large Pneumothorax

• First-line: Simple aspiration (success rate 59-83%)
  • Higher success rates in pneumothoraces <50% or <2 cm and in patients <50 years old
• If aspiration fails: Chest tube drainage
  • Small-bore (≤14F) for most cases
  • Moderate size (16F-22F) for larger pneumothoraces or significant air leak 2, 1

4. Secondary Pneumothorax

• Management: More aggressive approach required
• Observation: Only for very small pneumothoraces without symptoms
• Hospitalization: Required for 24 hours even after successful aspiration
• Chest tube: Usually required (16F-22F) 2, 1

5. Persistent Air Leak or Failure of Lung Re-expansion

• Referral timing: Consider surgical referral if air leak persists beyond 5-7 days
• Surgical options: Video-assisted thoracoscopy for surgical pleurodesis, thoracotomy, or bullectomy 1

Special Considerations

Cystic Fibrosis

• Approach: Early and aggressive treatment recommended
• Surgical intervention: Consider after first episode if patient is fit
• Success rate: Partial pleurectomy has 95% success rate with little reduction in pulmonary function 2

Mechanical Ventilation

• Risk: Positive pressure ventilation can convert small pneumothorax to tension pneumothorax
• Tube size: Consider larger tubes (24F-28F) for patients requiring positive-pressure ventilation 2, 4

Chest Tube Removal

• Timing: After complete resolution of pneumothorax and no clinical evidence of ongoing air leak
• Process:
  1. Discontinue any suction
  2. Repeat chest radiograph 5-12 hours after last evidence of air leak
  3. Remove tube while patient holds breath in full inspiration 2

Post-Treatment Care and Prevention

Follow-up

• Timing: Within 12-48 hours for patients managed conservatively
• Imaging: Chest radiograph to confirm complete resolution
• Specialist referral: Follow-up with respiratory physician recommended 2, 1

Activity Restrictions

• Air travel: Avoid for at least 7 days after radiological confirmation of complete resolution
• Diving: Permanently avoid after pneumothorax unless patient has had bilateral surgical pleurectomy 2, 1

Patient Education

• Warning signs: Return immediately if breathlessness develops
• Recurrence risk: Counsel regarding risk of recurrence
• Smoking cessation: Advise if applicable 1

Common Pitfalls and Caveats

• Clinical assessment limitations: Symptoms are not reliable indicators of pneumothorax size
• Delayed diagnosis: Tension pneumothorax may present with non-specific symptoms
• Occult pneumothorax: Small pneumothoraces can progress to tension pneumothorax with positive pressure ventilation 1, 4, 5
• Underestimation: Plain PA radiographs often underestimate pneumothorax size 1