What is the treatment for pneumothorax?

Treatment of Pneumothorax

The treatment of pneumothorax requires immediate intervention based on the type, size, and clinical presentation, with chest tube placement being the primary treatment for most clinically significant pneumothoraces to reexpand the lung and prevent mortality. 1

Classification and Initial Assessment

• Pneumothorax is classified as primary (no underlying lung disease) or secondary (with underlying lung disease), with treatment approaches differing between these types 1
• Size determination is crucial for management decisions:
  • Small: <3 cm apex-to-cupola distance
  • Large: ≥3 cm apex-to-cupola distance 1
• Clinical stability assessment is essential:
  • Stable: respiratory rate <24 breaths/min, heart rate 60-120 beats/min, normal BP, O2 saturation >90%, able to speak in whole sentences
  • Unstable: not meeting stability criteria 1

Treatment Algorithm Based on Clinical Presentation

1. Tension Pneumothorax (Medical Emergency)

• Immediate decompression with a cannula in the second intercostal space in the mid-clavicular line is required, followed by chest tube placement 1
• This life-threatening condition presents with rapid deterioration, respiratory distress, cyanosis, tachycardia, and hypotension 1
• Particularly common in mechanically ventilated patients who suddenly deteriorate 1, 2

2. Primary Spontaneous Pneumothorax

• Small, asymptomatic: Conservative management with observation and follow-up 1
• Symptomatic or large:
  • First-line: Simple aspiration (success rate 59-83%) 1
  • If aspiration fails: Small-bore catheter (≤14F) or chest tube (16F-22F) 1
  • Chest tube should be attached to either a Heimlich valve or water seal device 1
  • Apply suction if the lung fails to reexpand quickly 1

3. Secondary Spontaneous Pneumothorax

• Small, minimally symptomatic in patients <50 years: Consider simple aspiration (success rate 33-67%) 1
• Large or symptomatic: Chest tube insertion (16F-22F) 1
• Unstable patients: 24F-28F chest tube, especially if mechanical ventilation is required 1
• All secondary pneumothorax patients: Should be hospitalized due to higher risk of complications 1

Chest Tube Management

• Tube size selection:
  • Small-bore (≤14F): Suitable for primary pneumothorax or small secondary pneumothorax 1
  • Medium (16F-22F): Standard for most pneumothoraces 1
  • Large (24F-28F): For unstable patients, anticipated large air leaks, or mechanical ventilation 1
• Drainage system:
  • Water seal without suction initially, adding suction if lung fails to reexpand 1
  • Heimlich valve is an alternative, particularly for ambulatory management 1
• Chest tube removal:
  • Remove after radiographic confirmation of lung reexpansion and resolution of air leak 1
  • Staged removal process: discontinue suction first, then remove tube after confirming no recurrence 1

Special Populations

Cystic Fibrosis

• Early and aggressive treatment with intercostal tube drainage 1
• Surgical intervention (pleurectomy) should be considered after first episode due to high recurrence rate (50%) 1

HIV/AIDS

• Aggressive treatment with intercostal tube drainage and early surgical referral 1
• Higher incidence of bilateral (40%) and recurrent pneumothoraces with prolonged air leaks 1

Prevention of Recurrence

• Secondary pneumothorax: Consider intervention after first occurrence due to potential lethality 1
• Primary pneumothorax: Typically consider intervention after second occurrence 1
• Preferred interventions:
  • Surgical approach: Medical or surgical thoracoscopy with staple bullectomy and pleural symphysis (pleurectomy or pleural abrasion) 1
  • Chemical pleurodesis: Talc slurry or doxycycline for patients not suitable for surgery 1

Post-Treatment Considerations

• Patients should avoid air travel until complete resolution is confirmed by chest radiograph 1
• Diving should be permanently avoided unless bilateral surgical pleurectomy has been performed 1
• Follow-up chest radiograph recommended 2 weeks after discharge for patients managed conservatively 1

Common Pitfalls to Avoid

• Delaying treatment for tension pneumothorax while waiting for radiographic confirmation 1, 2
• Using inappropriately sized chest tubes (too small for unstable patients or too large for stable patients) 1
• Failing to recognize that positive pressure ventilation can convert a small asymptomatic pneumothorax into tension pneumothorax 2
• Discharging secondary pneumothorax patients too early after successful aspiration (should be observed for 24 hours) 1