What is the treatment for spontaneous pneumothorax?

Treatment of Spontaneous Pneumothorax

The treatment of spontaneous pneumothorax should be based on pneumothorax size, patient stability, and whether it is primary or secondary, with simple aspiration as first-line treatment for symptomatic primary pneumothorax and chest tube drainage for secondary or large pneumothoraces. 1

Classification and Initial Assessment

• Spontaneous pneumothorax is classified as primary (no underlying lung disease) or secondary (with underlying lung disease) 2
• Size determination is critical: small (<3 cm apex-to-cupola distance) vs. large (≥3 cm apex-to-cupola distance) 2
• Clinical stability assessment includes: respiratory rate <24 breaths/min, heart rate 60-120 beats/min, normal BP, room air O₂ saturation >90%, and ability to speak in full sentences 2
• High-flow oxygen (10 L/min) should be administered to increase the rate of pneumothorax reabsorption 1

Treatment Algorithm Based on Type and Size

Primary Spontaneous Pneumothorax

• Small and minimally symptomatic:

  • Observation alone may be sufficient 1
  • Patient should be instructed to return if breathlessness develops 1

• Symptomatic or large:

  • Simple aspiration as first-line treatment (success rate 59-83%) 1
  • Technique: Local anesthetic infiltration to pleura, insertion of cannula (French gauge 16 or larger) in second intercostal space mid-clavicular line, aspiration with 50 ml syringe connected to three-way tap 2
  • Repeat aspiration is reasonable if first attempt fails 1
  • If aspiration fails, proceed to intercostal tube drainage 1

Secondary Spontaneous Pneumothorax

• Intercostal tube drainage is recommended as initial treatment 1
• Patients with secondary pneumothorax should be hospitalized even if successfully treated with aspiration 1
• More aggressive management is needed for patients with cystic fibrosis, with consideration of surgical intervention after first episode 2

Chest Tube Management

• For most patients:

  • Use small-bore catheter (≤14F) or moderate-sized chest tube (16F-22F) 2
  • Tubes may be attached to either a Heimlich valve or water seal device 2

• For unstable patients or anticipated large air leak:

  • Consider larger chest tube (24F-28F) 2
  • Apply suction if the lung fails to re-expand with water seal drainage 2

• Chest tube removal:

  • Remove in staged manner after confirming resolution of pneumothorax and absence of air leak 2
  • Discontinue any suction before removal 2
  • Repeat chest radiograph 5-12 hours after last evidence of air leak 2

Special Considerations

• AIDS-related pneumothorax:

  • Often associated with Pneumocystis carinii infection 2
  • More likely to be bilateral (40%), have prolonged air leaks, and recur 2
  • Requires more aggressive management 2

• Cystic fibrosis patients:

  • Early and aggressive treatment recommended 2
  • Consider surgical intervention after first episode 2
  • Median survival after pneumothorax in CF patients is 30 months 2

Prevention of Recurrence

• For recurrent pneumothoraces, definitive measures to prevent further recurrence should be implemented 3
• Options include:
  • Chemical pleurodesis (talc poudrage) under thoracoscopy 4
  • Surgical approaches (video-assisted thoracic surgery) 4

Post-Treatment Follow-up

• Patients discharged without intervention should have follow-up chest radiograph after 2 weeks 2
• Avoid air travel until chest radiograph confirms complete resolution 2
• Diving should be permanently avoided unless bilateral surgical pleurectomy has been performed 2
• Provide adequate analgesia for patient comfort 2

Common Pitfalls and Caveats

• Tension pneumothorax requires immediate decompression and is a medical emergency 2
• Failure to aspirate may be due to cannula being withdrawn from pleural cavity or becoming kinked 2
• Persistent air leaks may require specialist respiratory consultation 2
• In chronic lung disease, drainage procedures are less successful and respiratory specialist referral is more likely 2