What are the management steps for pneumothorax, including chest tube (chest tube) insertion, maintenance, and drainage systems, as well as decompression needle insertion for tension pneumothorax?

Management of Pneumothorax and Tension Pneumothorax

For tension pneumothorax, immediate needle decompression using a cannula of at least 4.5 cm length (preferably 7 cm) should be performed in the second intercostal space in the mid-clavicular line, followed by chest tube insertion. 1

Tension Pneumothorax Recognition and Emergency Management

• Tension pneumothorax presents with rapid labored respiration, cyanosis, sweating, tachycardia, and progressive respiratory distress 2, 1
• It should be particularly suspected in patients on mechanical ventilation or non-invasive ventilation who suddenly deteriorate or develop pulseless electrical activity (PEA) 1
• Immediate management steps:
  • Insert a cannula of adequate length (minimum 4.5 cm, preferably 7 cm) into the second intercostal space in the mid-clavicular line 2, 1
  • Standard 3.2 cm catheters fail in up to 65% of cases, while 4.5 cm catheters have only a 4% failure rate 3
  • Leave the decompression cannula in place until a functioning intercostal tube can be positioned 2
  • Confirm proper function by observing bubbling in the underwater seal system 2, 1

Chest Tube Insertion for Pneumothorax

• After needle decompression in tension pneumothorax, or as primary treatment for significant pneumothorax, insert a chest tube 2
• For standard pneumothorax, a small gauge drain is usually adequate 2
• Insertion steps:
  • Administer adequate local anesthesia 1
  • Position tube in the appropriate intercostal space (usually 4th-5th intercostal space, mid-axillary line) 1
  • Connect to underwater seal drainage system 1
  • Obtain chest radiograph to confirm tube position and lung re-expansion 1

Chest Tube Maintenance and Drainage Systems

• Most clinicians attach drains to an underwater seal system 2
• The Heimlich one-way flutter valve is an alternative that allows outpatient management 2
• If the pneumothorax continues to enlarge or the patient develops surgical emphysema with a flutter valve, replace it with an underwater seal system 2
• Monitor for:
  • Air leak persistence 1
  • Proper tube position 1
  • Adequate drainage 1
  • Complications including infection or tube displacement 1

Common Pitfalls to Avoid

• Delay in treatment while waiting for radiographic confirmation - tension pneumothorax is a clinical diagnosis requiring immediate intervention 1
• Using needles that are too short - chest wall thickness often exceeds 3 cm in 57% of patients 2, 4
• Removing the decompression cannula before a functioning chest tube is in place 1
• Clamping chest tubes inappropriately 2
• Inadequate analgesia during and after procedures 1

Special Considerations

• For patients with CF or severe underlying lung disease, pneumothorax may require longer management and has higher recurrence rates 2
• Patients on positive pressure ventilation who develop pneumothorax should always receive tube thoracostomy as positive pressure maintains the air leak 1
• Consider surgical options (pleurectomy, pleural abrasion) for recurrent pneumothoraces, particularly in CF patients 2
• Patients should not travel by air within 6 weeks of thoracic surgery or resolution of a spontaneous pneumothorax 2