What are the latest treatment guidelines for spontaneous pneumothorax?

Management Guidelines for Spontaneous Pneumothorax

The treatment of spontaneous pneumothorax should be based on classification (primary vs. secondary), size of pneumothorax, and patient symptoms, with observation recommended for small asymptomatic pneumothoraces and more invasive interventions for larger or symptomatic cases. 1

Classification and Size Assessment

• Pneumothorax is classified as "small" when there is a visible rim of <2 cm between lung margin and chest wall, and "large" when the rim is >2 cm 1
• Primary spontaneous pneumothorax (PSP) occurs in patients without underlying lung disease, while secondary spontaneous pneumothorax (SSP) occurs in patients with underlying lung pathology 1
• Plain PA radiograph often underestimates pneumothorax size; CT scanning is the most accurate method for size assessment but is only recommended in complex cases 1

Treatment Algorithm

1. Observation

• Small primary pneumothorax (<2 cm) with minimal symptoms:

  • Observation alone is recommended 1
  • Patients may be considered for discharge with early outpatient review 1
  • Clear written instructions should be provided to return if breathlessness worsens 1

• Small secondary pneumothorax (<1 cm or isolated apical) with minimal symptoms:

  • Observation with hospital admission is recommended 1
  • High flow oxygen (10 L/min) should be administered to increase reabsorption rate (with caution in COPD patients) 1

2. Simple Aspiration

• Primary pneumothorax requiring intervention:

  • Simple aspiration is recommended as first-line treatment 1
  • Success rates are higher in patients under 50 years (70-81%) compared to those over 50 (19-31%) 1
  • Repeated aspiration is reasonable when first attempt fails and <2.5L was aspirated 1

• Small secondary pneumothorax (<2 cm) in minimally breathless patients under 50:

  • Simple aspiration may be attempted, but success rates are lower (33-67%) than in primary pneumothorax 1
  • Hospital admission for at least 24 hours observation is required 1

3. Intercostal Tube Drainage

• Failed aspiration in any pneumothorax:

  • Intercostal tube drainage should be inserted if aspiration fails to control symptoms 1

• Large secondary pneumothorax (>2 cm), especially in patients over 50:

  • Immediate intercostal tube drainage is recommended due to high risk of aspiration failure 1

• Any breathless patient regardless of pneumothorax size:

  • Active intervention is required; breathless patients should never be left without intervention 1

4. Surgical Intervention

• Persistent air leak or recurrent pneumothorax:
  • Consider surgical intervention (pleurectomy, pleural abrasion, or talc pleurodesis) 1
  • In cystic fibrosis patients, surgical intervention should be considered after the first episode if the patient is fit for surgery 1

Special Considerations

Tension Pneumothorax

• If tension pneumothorax is suspected (sudden deterioration, cyanosis, tachycardia, hypotension):
  • Immediately insert a cannula of adequate length into the second intercostal space in the mid-clavicular line 1
  • Leave the cannula in place until a functioning intercostal tube can be positioned 1
  • Note that standard 3-6 cm cannulas may be too short in 57% of patients 1

Cystic Fibrosis

• Early and aggressive treatment is recommended for pneumothoraces in cystic fibrosis patients 1
• Surgical intervention should be considered after the first episode if the patient is fit for the procedure 1
• Partial pleurectomy has a 95% success rate with little reduction in pulmonary function 1

Important Precautions

• A bubbling chest tube should never be clamped 1
• Non-bubbling chest tubes should generally not be clamped 1
• If a chest tube is clamped, it should be under specialist supervision in a dedicated ward 1
• Patients should be cautioned against flying until follow-up chest radiograph confirms complete resolution 1

Complications to Monitor

• Intercostal tube drainage can cause serious complications including organ penetration 1
• Complications are more common when sharp metal trocars are used during the procedure 1
• Persistent air leak (>5 days) occurs in 16% of primary and 31% of secondary pneumothoraces 2
• Recurrence rates are higher in patients treated with drainage (17%) compared to those treated without drainage (5%) 2