What is the appropriate management for a patient with pneumothorax (collapsed lung)?

Management of Pneumothorax

The appropriate management of pneumothorax requires a procedure to reexpand the lung based on the size of pneumothorax, clinical stability of the patient, and whether it is primary or secondary in nature, with most patients requiring hospitalization and chest tube placement. 1

Classification and Initial Assessment

• Pneumothorax is classified as primary (no underlying lung disease) or secondary (with underlying lung disease such as COPD) 1, 2
• Size classification: small (<2-3 cm apex-to-cupola distance) or large (≥3 cm apex-to-cupola distance) 1, 2
• Clinical stability assessment is crucial: stable patients have respiratory rate <24 breaths/min, heart rate 60-120 beats/min, normal BP, room air O₂ saturation >90%, and can speak in whole sentences between breaths 1

Management Based on Clinical Presentation

Clinically Stable Patients with Small Pneumothorax

• Primary pneumothorax: Observation alone may be appropriate for minimally symptomatic patients 2
• Secondary pneumothorax: Observation alone only for asymptomatic patients, but hospitalization is recommended 2
• High-flow oxygen (10 L/min) should be administered to hospitalized patients to accelerate reabsorption of trapped air 3

Clinically Stable Patients with Large Pneumothorax

• Procedure to reexpand the lung and hospitalization is recommended in most cases 1
• Options include:
  • Small-bore catheter (≤14F) or moderate-sized chest tube (16F-22F) 1
  • Catheters/tubes can be attached to a Heimlich valve or water seal device 1
  • If the lung fails to reexpand quickly, suction should be applied 1

Clinically Unstable Patients with Large Pneumothorax

• Immediate hospitalization with chest catheter insertion is required 1
• Most patients should be treated with a 16F-22F standard chest tube or small-bore catheter depending on clinical instability 1
• Larger chest tubes (24F-28F) may be necessary for patients with anticipated bronchopleural fistula or those requiring positive-pressure ventilation 1
• Initial water seal device without suction is appropriate, with suction applied if the lung fails to reexpand 1

Special Considerations

• For patients with tension pneumothorax (mediastinal shift with hemodynamic compromise), immediate decompression is required 1
• Oxygen administration at high flow (10 L/min) can increase pneumothorax reabsorption up to four times faster than breathing ambient air 3
• Caution should be exercised when administering high-concentration oxygen to patients with COPD who may be at risk for hypercapnic respiratory failure 3

Chest Tube Management and Removal

• Chest tubes should be removed in a staged manner to ensure air leaks have resolved 1
• First stage: Chest radiograph must demonstrate complete resolution of pneumothorax with no clinical evidence of ongoing air leak 1
• Any applied suction should be discontinued before tube removal 1
• Persistent air leaks (beyond 7-14 days) may require surgical intervention, particularly in secondary pneumothorax 4

Recurrence Prevention

• Surgical intervention should be considered after the first recurrence of pneumothorax 2
• Options include staple bullectomy, parietal pleurectomy, talc poudrage, or pleural abrasion 2
• Smoking cessation reduces the risk of future recurrence in active smokers 5

Follow-up Recommendations

• Patients discharged without intervention should have follow-up chest radiograph after 2 weeks 2
• Air travel should be avoided until chest radiograph confirms pneumothorax resolution 2
• Diving should be permanently avoided after pneumothorax unless the patient has had bilateral surgical pleurectomy 2