What are the management options for pneumothorax (collapsed lung)?

Management of Pneumothorax

The management of pneumothorax should be based on pneumothorax type, size, and patient stability, with immediate needle decompression for tension pneumothorax, observation for small asymptomatic primary pneumothorax, simple aspiration for symptomatic primary pneumothorax, and chest tube placement for secondary pneumothorax or failed aspiration. 1

Initial Assessment and Classification

Pneumothorax is classified as:

1. Primary spontaneous pneumothorax: Occurs without apparent cause in healthy individuals
2. Secondary spontaneous pneumothorax: Occurs in patients with underlying lung disease
3. Traumatic pneumothorax: Result of chest trauma
4. Iatrogenic pneumothorax: Complication of medical procedures

Size classification 1:

• Small: <2 cm rim between lung margin and chest wall
• Moderate: Lung collapsed halfway toward heart border
• Complete: Airless lung, separate from diaphragm
• Tension: Pneumothorax with cardiorespiratory collapse (requires immediate intervention)

Management Algorithm

Tension Pneumothorax (Emergency)

• Immediate needle decompression with large-bore cannula in 2nd intercostal space, mid-clavicular line 1
• Follow with chest tube placement
• Do not wait for radiographic confirmation if clinical signs are present (tachycardia, hypotension, hypoxemia, increased airway pressure) 2

Primary Spontaneous Pneumothorax

1. Small and Asymptomatic:

   • Observation without intervention 1
   • High-flow oxygen (10 L/min) to increase reabsorption rate if hospitalized 1
   • Outpatient management if patient lives within 30 minutes of hospital and has adequate support 1

2. Large or Symptomatic:

   • Simple aspiration as first-line treatment 3, 1
     • Success rates: 77% for <50% pneumothorax, 62% for >50% pneumothorax 1
     • Use local anesthetic, 16F or larger cannula (≥3cm long)
     • Discontinue if resistance felt, excessive coughing occurs, or >25ml air aspirated 3
   • If aspiration fails, proceed to chest tube placement

Secondary Spontaneous Pneumothorax

• Chest tube drainage (16F-22F) as first-line treatment 3, 1
• Hospitalization required regardless of size 3
• Consider premedication with atropine to prevent vasovagal reactions 3
• Observe overnight even after successful aspiration 3

Chest Tube Management

• Stable patients: 16F-22F chest tubes 3
• Unstable patients or those requiring mechanical ventilation: 24F-28F chest tubes 3
• Connect to water seal device with or without suction 3
• If lung fails to expand with water seal alone, add suction 3
• Consider Heimlich valve for ambulatory management in selected cases 3

Recurrence Prevention

• After first recurrence of primary pneumothorax or first episode of secondary pneumothorax 3, 1
• Preferred approach: Video-assisted thoracoscopic surgery (VATS) 3, 1
  • Includes bullectomy and pleural symphysis procedure
  • Options for pleural symphysis: parietal pleurectomy, talc poudrage, or pleural abrasion 3
• Alternative for poor surgical candidates: Chemical pleurodesis via chest tube
  • Preferred agents: talc slurry (very good consensus) or doxycycline 3

Special Considerations

Traumatic Pneumothorax

• Most require chest tube placement 4
• Small, asymptomatic traumatic pneumothoraces may be observed in selected cases 4
• Lung ultrasound is more sensitive than chest X-ray for diagnosis 4

Iatrogenic Pneumothorax

• Common after transthoracic needle biopsy and central line placement 5
• Management depends on size and patient stability
• Small-bore catheters or pigtail catheters are increasingly used as alternatives to traditional large-bore chest tubes 4

Pitfalls and Caveats

• Delayed recognition of tension pneumothorax can be fatal 1
• Clinical symptoms are not reliable indicators of pneumothorax size 1
• Small asymptomatic pneumothorax can progress to tension pneumothorax with positive pressure ventilation 2
• Failure of aspiration may be due to cannula being inadvertently withdrawn or kinked 3
• Patients should avoid air travel for at least 7 days after complete resolution 1

Follow-up

• Follow-up chest X-ray to confirm resolution
• Clear discharge instructions with warning signs requiring immediate return
• Smoking cessation counseling for patients who smoke
• Referral to thoracic surgery if air leak persists beyond 5-7 days 1