Emergency Management of Pneumothorax
The emergency care for a patient with pneumothorax requires immediate assessment of clinical stability and pneumothorax size, followed by appropriate decompression procedures based on these factors. 1
Initial Assessment
- Evaluate clinical stability: Assess respiratory rate (<24 breaths/min), heart rate (60-120 beats/min), blood pressure, oxygen saturation (>90%), and ability to speak in complete sentences between breaths 1
- Check for signs of tension pneumothorax: Progressive dyspnea, tachycardia, hypotension, and cyanosis in severe cases 2
- Determine pneumothorax size: Small (<3 cm apex-to-cupola distance) vs. large (≥3 cm apex-to-cupola distance) on upright chest radiograph 1
- Assess for diminished breath sounds, hyperresonance on percussion, and decreased chest wall movement on the affected side 2
Management Algorithm Based on Clinical Presentation
For Clinically Stable Patients with Small Pneumothorax:
- Observe in the emergency department for 3-6 hours 1
- Obtain repeat chest radiograph to exclude progression 1
- Discharge home if no progression with follow-up within 12 hours to 2 days 1
- Simple aspiration or chest tube insertion is not appropriate unless the pneumothorax enlarges 1
For Clinically Stable Patients with Large Pneumothorax:
- Perform a procedure to reexpand the lung and hospitalize in most instances 1
- Use either:
- Small-bore catheter (≤14F) or
- Moderate-sized chest tube (16F to 22F) 1
- Attach to either:
- Heimlich valve or
- Water seal device 1
- Apply suction if the lung fails to reexpand quickly 1
- For reliable patients unwilling to be hospitalized: Consider discharge with small-bore catheter attached to Heimlich valve if the lung has reexpanded, with follow-up within 2 days 1
For Clinically Unstable Patients with Large Pneumothorax:
- Hospitalize with immediate insertion of a chest catheter 1
- Use either:
- Moderate-sized chest tube (16F to 22F) or
- Small-bore catheter, depending on clinical instability 1
- Consider larger chest tube (24F to 28F) if bronchopleural fistula with large air leak is anticipated or if positive-pressure ventilation is required 1
- Initially use water seal device without suction, but apply suction if lung fails to reexpand 1
For Tension Pneumothorax (Medical Emergency):
- Perform immediate needle decompression in the second intercostal space in the mid-clavicular line using a cannula (French gauge 16 or larger and at least 3 cm long) 1
- Follow with formal chest tube insertion after stabilization 1, 3
- Monitor for hemodynamic improvement after decompression 4
Special Considerations
- Patients with underlying lung disease (secondary spontaneous pneumothorax) typically present with more severe symptoms and may require more aggressive management 2, 3
- Positive pressure ventilation can exacerbate a small pneumothorax into a tension pneumothorax 4, 3
- In patients with asthma, tension pneumothorax is a rare but potentially reversible cause of arrest that requires immediate recognition and treatment 1
- Ultrasound has emerged as a useful diagnostic tool for pneumothorax detection in emergency settings, potentially more sensitive than chest X-ray 5, 3
Procedural Notes for Needle Decompression
- Explain the procedure to the patient and provide reassurance 1
- Consider premedication with atropine to prevent vasovagal reaction 1
- Use local anesthetic infiltrated down to the pleura 1
- Insert the cannula and withdraw the needle, connecting to a three-way tap and syringe 1
- Discontinue aspiration if resistance is felt, patient coughs excessively, or more than 25 ml is aspirated 1
- Obtain repeat chest radiograph to confirm effectiveness 1
Post-Procedure Care
- Monitor vital signs and respiratory status 1
- Keep chest tube or catheter in place until the lung expands against the chest wall and air leaks have resolved 1
- Arrange appropriate follow-up within 2 days for discharged patients 1
- Consider thoracic surgery consultation for persistent air leak or failure of lung re-expansion 3