What is the management for a patient with pneumothorax post-Implantable Cardioverter-Defibrillator (ICD) insertion who has no lung expansion?

Management of Pneumothorax with No Lung Expansion After Chest Drain Insertion

If the lung fails to re-expand after chest drain insertion for pneumothorax, apply suction to the water-seal drainage system and refer to a respiratory specialist if there is no improvement within 48 hours. 1

Initial Management Steps

Apply Suction to the Drainage System

• If the lung fails to re-expand quickly after chest drain insertion, suction should be applied to the water-seal device. 1
• High volume, low pressure suction systems (–10 to –20 cm H₂O) are recommended. 1
• Suction can be applied immediately after chest tube placement or after 48 hours if initial water seal drainage fails. 1
• Avoid high pressure, high volume systems as they can cause air stealing, hypoxemia, or perpetuate persistent air leaks. 1

Verify Proper Drain Position and Function

• Ensure the chest drain is properly positioned and not kinked or blocked. 1
• Confirm adequate drain size—a 16F to 22F chest tube is typically appropriate for most pneumothoraces. 1
• For patients with anticipated large air leaks or those requiring positive-pressure ventilation, a 24F to 28F chest tube may be necessary. 1

Persistent Non-Expansion: Specialist Referral

Timing of Referral

• Pneumothoraces that fail to respond within 48 hours to treatment should be referred to a respiratory physician. 1
• Failure of lung re-expansion or persistent air leak exceeding 48 hours duration should prompt referral to a respiratory specialist. 1
• These patients require complex drain management including suction optimization, potential drain repositioning, and thoracic surgery consultation decisions. 1

Consider Non-Expandable Lung

The lung may fail to expand due to underlying pathology preventing full re-expansion:

• Non-expandable lung can occur due to visceral pleural restriction, endobronchial obstruction, or underlying lung disease. 1
• In cases of radiologically significant (>25%) non-expandable lung, consider alternative management strategies beyond simple drainage. 1

Advanced Management Options

Surgical Consultation

• Earlier surgical referral (2–4 days) should be considered in patients with underlying lung disease, large persistent air leak, or failure of lung re-expansion. 1
• Decortication surgery may improve outcomes in selected patients with non-expandable lung, particularly those fit enough for thoracic surgery. 1
• The risks and benefits of surgical intervention versus continued conservative management should be discussed with the patient. 1

Alternative Drainage Strategies

• For persistent non-expansion despite adequate suction, consider drain repositioning or insertion of an additional chest drain if loculated pneumothorax is suspected. 1
• In highly selected cases with non-expandable lung and persistent symptoms, an indwelling pleural catheter (IPC) may be considered for long-term management, though this is more commonly used for malignant effusions. 1

Common Pitfalls to Avoid

• Do not apply suction immediately after tube insertion—allow initial water seal drainage first unless the patient is clinically unstable. 1
• Do not delay specialist referral beyond 48 hours if there is no improvement, as prolonged air leaks increase morbidity and hospital stay. 1
• Do not use inadequate suction systems—ensure high volume, low pressure capacity (15–20 L/min air flow volume). 1
• Be aware that positive pressure ventilation can worsen pneumothorax and prevent re-expansion in mechanically ventilated patients. 2, 3

Monitoring During Treatment

• Obtain serial chest radiographs to assess lung re-expansion. 1
• Monitor for signs of tension pneumothorax, particularly in ventilated patients: tachycardia, hypotension, hypoxemia, and increasing airway pressures. 2
• Assess for ongoing air leak by observing bubbling in the water seal chamber. 1
• In ICU patients with respiratory failure, maintain high clinical suspicion as pneumothorax can rapidly progress to tension physiology. 3