What is the treatment for a large pneumothorax?

Treatment of Large Pneumothorax

For a large pneumothorax, chest tube placement (16F-22F) connected to a water seal device is the recommended first-line treatment, followed by hospitalization for monitoring until the lung fully re-expands and air leaks resolve. 1

Initial Management

• Definition: A large pneumothorax is defined as ≥3 cm apex-to-cupola distance on an upright chest radiograph 1
• Clinical assessment: Evaluate for stability (respiratory rate <24 breaths/min, heart rate 60-120 beats/min, normal BP, room air O2 saturation >90%, ability to speak in whole sentences) 1
• Imaging: Chest radiograph is the primary diagnostic tool; CT scanning is not routinely recommended for first-time pneumothorax 1

Treatment Algorithm

For Clinically Stable Patients with Large Pneumothorax:

1. Immediate intervention: Place chest tube to re-expand the lung 1

   • Use small-bore catheter (≤14F) or moderate-sized chest tube (16F-22F) 1, 2
   • Avoid the outdated trocar technique; use blunt dissection or Seldinger technique 3

2. Drainage system options:

   • Water seal device with or without suction (preferred option) 1, 2
   • Apply suction if the lung fails to re-expand quickly 1
   • Heimlich valve is an acceptable alternative 1

3. Hospitalization: Required for all patients with large pneumothorax 1

For Clinically Unstable Patients with Pneumothorax (Any Size):

1. Emergency chest tube placement: Use 24F-28F tube, especially if mechanical ventilation is required 1
2. Immediate hospitalization: Required for all unstable patients 1
3. Water seal with suction: More commonly needed in unstable patients 1

Chest Tube Management

• Confirmation of proper placement: Check for respiratory swing in fluid level within chest tube 2
• Monitoring for air leak: Continuous bubbling in water seal chamber indicates ongoing air leak 2
• Pain management: Provide adequate analgesia during placement and removal 2
• Tube removal criteria:
  • Complete lung re-expansion confirmed by chest radiograph
  • Resolution of air leak
  • Clinical stability 2
  • Remove during expiration or Valsalva maneuver 2

Prevention of Recurrence

For secondary pneumothorax, consider recurrence prevention after first occurrence due to potential lethality 1:

1. Surgical options (preferred approach):

   • Video-assisted thoracoscopic surgery (VATS) 1, 2
   • Staple bullectomy with pleural symphysis 1
   • Parietal pleurectomy or pleural abrasion (limited to upper half of hemithorax) 1

2. Chemical pleurodesis (if surgery contraindicated):

   • Doxycycline or talc slurry through chest tube 1

Common Pitfalls and Caveats

• Tube size selection: While traditional teaching favored large-bore tubes, evidence suggests smaller tubes (≤14F) are effective for most pneumothoraces and cause less pain 3, 4
• Tube occlusion: More common with small-bore tubes; may require flushing with normal saline if blocked 2
• Tension pneumothorax: Life-threatening emergency requiring immediate decompression; clinical signs may correlate poorly with radiographic findings 2
• Post-discharge precautions: Patients should avoid air travel until complete resolution plus 7 days, and permanently avoid scuba diving unless surgical pleurectomy has been performed 2

For traumatic pneumothorax specifically, a pneumothorax greater than 20% of thoracic volume on chest x-ray or greater than 35 mm on CT should be treated with tube thoracostomy 5.