Treatment of Pneumothorax
The treatment of pneumothorax requires a chest tube to reexpand the lung, with the specific approach determined by the clinical stability of the patient and the size of the pneumothorax. 1
Classification and Initial Assessment
- Pneumothorax is classified as primary (no underlying lung disease) or secondary (occurs with existing lung pathology) 1
- Clinical stability assessment is crucial for determining treatment approach:
- Size classification:
- Small: <3 cm apex-to-cupola distance
- Large: ≥3 cm apex-to-cupola distance 1
Treatment Algorithm
1. Tension Pneumothorax (Medical Emergency)
- Immediately insert a cannula into the second intercostal space in the mid-clavicular line 1
- Follow with prompt placement of a functioning intercostal tube 1
- Signs include rapid deterioration, labored breathing, cyanosis, sweating, tachycardia, and hypotension 1
2. Clinically Stable Patients with Small Pneumothorax
- Primary pneumothorax: Observation may be appropriate if minimally symptomatic 1
- Secondary pneumothorax: Simple aspiration may be attempted in patients under 50 years who are minimally breathless 1
- Supplemental high-flow oxygen (10 L/min) should be given to hospitalized patients to increase reabsorption rate 1
3. Clinically Stable Patients with Large Pneumothorax
- Chest tube placement is recommended with hospitalization 1
- For primary pneumothorax: Simple aspiration is recommended as first-line treatment 1
- For secondary pneumothorax: Chest tube drainage is preferred due to lower success rates with aspiration (33-67%) 1
4. Clinically Unstable Patients (Any Size Pneumothorax)
- Immediate chest tube placement and hospitalization 1
- Use 16F to 22F chest tube for most patients 1
- Use 24F to 28F chest tube for patients with anticipated large air leaks or those requiring mechanical ventilation 1
- Attach to water seal device with or without suction 1
Chest Tube Management
- Small-bore catheter (≤14F) or 16F to 22F chest tube is appropriate for most patients 1
- Attach to either:
- Apply suction if the lung fails to reexpand quickly 1
- Leave tube in place until the lung expands against the chest wall and air leaks resolve 1
Chest Tube Removal
- Ensure complete resolution of pneumothorax on chest radiograph 1
- Discontinue any suction 1
- Some clinicians clamp the tube for 4 hours after the last evidence of air leak, while others never clamp 1
- Repeat chest radiograph 5-12 hours after the last evidence of air leak before tube removal 1
Special Considerations
Cystic Fibrosis
- Early and aggressive treatment is recommended 1
- Consider surgical intervention after first episode if patient is fit for procedure 1
- Commence IV antibiotics to prevent sputum retention 1
HIV/AIDS
- Early and aggressive treatment with intercostal tube drainage and early surgical referral 1
- Consider Pneumocystis carinii infection as likely etiology 1
- Higher risk of bilateral (40%) and recurrent pneumothoraces 1
Recurrence Prevention
- For secondary pneumothorax: Consider intervention after first occurrence due to potential lethality 1
- Surgical approaches (thoracoscopy, bullectomy with pleural symphysis) are preferred over chemical pleurodesis 1
- Chemical pleurodesis options include doxycycline or talc slurry 1
Discharge and Follow-up
- Primary pneumothorax patients successfully treated with aspiration: Observe for clinical stability before discharge 1
- Secondary pneumothorax patients successfully treated with aspiration: Admit for 24 hours before discharge 1
- Avoid air travel until chest radiograph confirms complete resolution 1
- Diving should be permanently avoided unless bilateral surgical pleurectomy has been performed 1
- Follow-up chest radiograph after 2 weeks for patients discharged without intervention 1