What is the first step in managing a patient with pneumothorax?

Management of Pneumothorax: First Steps

The first step in managing a pneumothorax is to assess the patient's clinical stability and pneumothorax size, then provide supplemental oxygen (10-15 L/min via non-rebreather mask) while preparing for appropriate intervention based on pneumothorax size and symptoms. 1

Initial Assessment and Classification

1. Rapid clinical assessment:

   • Evaluate for dyspnea, chest pain, diminished breath sounds
   • Check vital signs: respiratory rate, heart rate, blood pressure, oxygen saturation
   • Assess for signs of tension pneumothorax (deviated trachea, hypotension, distended neck veins)

2. Radiographic assessment:

   • Obtain chest X-ray (PA view) to confirm diagnosis and estimate size 1
   • Size classification:
     • Small: <2 cm rim between lung margin and chest wall
     • Moderate: lung collapsed halfway toward heart border
     • Complete: airless lung, separate from diaphragm
     • Tension: requires immediate decompression 2

Immediate Management Algorithm

For ALL patients with confirmed pneumothorax:

• Administer high-flow oxygen (10 L/min or 15 L/min via reservoir mask) to increase reabsorption rate 1
• Monitor vital signs closely

For tension pneumothorax:

• Immediate needle decompression with large-bore cannula in 2nd intercostal space, mid-clavicular line 2
• Follow with chest tube placement

For symptomatic patients (regardless of pneumothorax size):

• Simple aspiration as first-line treatment for symptomatic pneumothoraces 1
  • Success rates: 77% for <50% pneumothorax, 62% for >50% pneumothorax 1
  • Procedure:
    • Local anesthetic infiltration to pleura
    • Insert cannula (≥16 French gauge, ≥3 cm long) in 2nd intercostal space, mid-clavicular line
    • Connect to three-way tap and 50 ml syringe
    • Discontinue if resistance felt, excessive coughing, or >25 ml aspirated 2
    • Obtain post-procedure chest X-ray

For asymptomatic small pneumothorax:

• Observation may be appropriate with supplemental oxygen 1
• Outpatient management possible if:
  • Patient lives within 30 minutes of hospital
  • Has adequate home support
  • Shows clinical stability (RR <24/min, HR 60-120/min, normal BP, O₂ sat >90%) 1

Important Considerations

• Never leave a dyspneic patient without intervention, regardless of pneumothorax size on imaging 1
• Patients with secondary pneumothorax (underlying lung disease) require more aggressive management and should be observed overnight even after aspiration 2
• Consider premedication with atropine to prevent vasovagal reactions during procedures 2
• For patients with anxiety, small doses of intravenous midazolam may be appropriate 2

Common Pitfalls to Avoid

1. Underestimating pneumothorax severity: Clinical symptoms are not reliable indicators of pneumothorax size; a small pneumothorax can cause significant symptoms in patients with underlying lung disease 1

2. Delayed recognition of tension pneumothorax: This is a life-threatening emergency requiring immediate decompression before imaging 2

3. Inadequate aspiration technique: Failure may be due to inadvertently withdrawn or kinked cannula; consider another attempt if suspected 2

4. Insufficient monitoring: Even small pneumothoraces can progress; ensure appropriate follow-up and clear instructions for when to return if managed conservatively 1