Treatment of Pneumothorax
The treatment of pneumothorax should be based on the type (primary vs. secondary), size, and patient's clinical stability, with chest tube insertion being the primary intervention for large or symptomatic pneumothoraces to reexpand the lung. 1
Classification and Initial Assessment
- Pneumothorax is classified as primary (no underlying lung disease) or secondary (with underlying lung disease such as COPD) 1
- Size determination is important for management decisions:
- Small: <3 cm apex-to-cupola distance
- Large: ≥3 cm apex-to-cupola distance 1
- Clinical stability assessment is crucial:
Treatment Algorithm
1. Tension Pneumothorax (Medical Emergency)
- Immediate decompression with cannula insertion into the second intercostal space in the mid-clavicular line 1
- Follow with formal chest tube placement once stabilized 1
2. Clinically Stable Patients with Small Primary Pneumothorax
- Observation may be appropriate for minimally symptomatic or asymptomatic patients 1
- Supplemental high-flow oxygen (10 L/min) to accelerate reabsorption 1
- Follow-up chest radiograph after 2 weeks 1
3. Clinically Stable Patients with Large Primary Pneumothorax
- Simple aspiration as first-line treatment 1
- If aspiration fails or pneumothorax recurs, proceed to chest tube placement 1
- Chest tube size: small-bore catheter (≤14F) or 16F-22F tube 1
- Attach to Heimlich valve or water seal device 1
4. Clinically Stable Patients with Secondary Pneumothorax
- Small secondary pneumothorax in minimally breathless patients <50 years: consider simple aspiration 1
- Most secondary pneumothoraces require chest tube placement (16F-22F) 1
- Hospitalization is recommended 1
- Attach tube to water seal device with or without suction 1
5. Clinically Unstable Patients (Any Pneumothorax Size)
- Immediate chest tube placement (16F-22F for most patients) 1
- Consider 24F-28F tube for patients with anticipated large air leaks or requiring mechanical ventilation 1
- Hospitalization is mandatory 1
- Water seal device initially without suction, but apply suction if lung fails to reexpand 1
Chest Tube Management
- Leave tube in place until:
- Complete resolution of pneumothorax on chest radiograph
- No clinical evidence of ongoing air leak 1
- Discontinue suction before removal 1
- Consider staged removal with follow-up chest radiograph 5-12 hours after last evidence of air leak 1
Special Considerations
Recurrence Prevention
- For primary pneumothorax: consider intervention after second occurrence 1
- For secondary pneumothorax: most experts recommend intervention after first occurrence due to potential lethality 1
- Preferred interventions:
Specific Patient Populations
Cystic Fibrosis Patients
- Early and aggressive treatment recommended 1
- Consider surgical intervention after first episode if patient is fit for procedure 1
- Partial pleurectomy has 95% success rate 1
HIV/AIDS Patients
- Early and aggressive treatment with intercostal tube drainage 1
- Early surgical referral recommended 1
- Consider treatment for Pneumocystis carinii infection 1
Post-Treatment Recommendations
- Avoid air travel until complete resolution confirmed by chest radiograph 1
- Permanently avoid diving unless bilateral surgical pleurectomy performed 1
- For patients treated with simple aspiration:
Common Pitfalls and Caveats
- Tension pneumothorax may present with minimal radiographic findings despite severe clinical compromise 1
- Small asymptomatic pneumothoraces can progress to tension pneumothorax with positive pressure ventilation 2
- Traditional large-bore chest tubes may not be necessary for all patients; smaller tubes or catheters can be equally effective in many cases 3
- Undetected pneumothorax during procedures like central line placement can lead to serious complications 2