What is the management and treatment for pneumothorax (collapsed lung)?

Management of Pneumothorax

For primary spontaneous pneumothorax in stable patients, simple aspiration should be attempted first, while secondary pneumothorax requires more aggressive treatment with chest tube drainage due to underlying lung disease and higher risk of complications. 1

Initial Assessment

Classify the Pneumothorax Type

• Primary spontaneous pneumothorax occurs in otherwise healthy young adults who can tolerate small air leaks 2
• Secondary spontaneous pneumothorax occurs in older patients with emphysema or underlying lung disease (cystic, fibrotic, bullous, or emphysematous), where even small pneumothoraces may cause severe respiratory failure 2
• Tension pneumothorax presents with cardiorespiratory collapse and requires immediate needle decompression 2

Assess Clinical Stability

• Evaluate respiratory rate, heart rate, blood pressure, oxygen saturation, and ability to speak in full sentences 1
• Significant dyspnea (obvious deterioration in usual exercise tolerance) requires aspiration regardless of pneumothorax size 2

Determine Size on Chest Radiograph

• Small: small rim of air around lung 2
• Moderate: lung collapsed halfway towards heart border 2
• Complete: airless lung, separate from diaphragm 2
• Alternative definition: small pneumothorax <3 cm apex-to-cupola distance, large ≥3 cm 1

Treatment Algorithm

Primary Spontaneous Pneumothorax

Small, Minimally Symptomatic:

• Observation alone may be sufficient with instructions to return if breathlessness develops 1
• Administer high-flow oxygen (10 L/min) to increase rate of pneumothorax reabsorption 1

Symptomatic or Large:

• Attempt simple aspiration first (success rate 59-83%) 1
• Technique: Infiltrate local anesthetic to pleura in second intercostal space mid-clavicular line (axillary approach is alternative) 2
• Use cannula French gauge 16 or larger, at least 3 cm long 2
• Connect cannula and 50 ml syringe to three-way tap to void aspirated air 2
• Discontinue if resistance felt, patient coughs excessively, or more than 2.5 L aspirated 2
• Repeated aspiration is reasonable if first attempt fails 1

If Aspiration Fails:

• Proceed to intercostal tube drainage using small-bore catheter (≤14F) or moderate-sized chest tube (16F-22F) 1

Secondary Spontaneous Pneumothorax

Initial Treatment:

• Intercostal tube drainage is recommended as initial treatment due to poor lung reserve and lower success rates with aspiration 1
• Use 16F-22F chest tube for most stable patients 1, 3
• For unstable patients or those at risk of large pleural air leaks requiring mechanical ventilation, use 24F-28F chest tube 3
• All patients with chronic lung disease must be observed overnight, whether or not they have had aspiration 2
• Referral to respiratory specialist is more likely as drainage procedures are less successful 2

Special Considerations

Tension Pneumothorax:

• Medical emergency requiring immediate needle decompression followed by chest tube insertion 4, 5

Crack Users and High-Risk Secondary Pneumothorax:

• Even small pneumothoraces require chest tube drainage as first-line treatment 4
• Immediate decompression with needle if hemodynamic instability or severe respiratory distress present 4

Chest Tube Management

Connection and Suction

• Connect chest tube to water seal device with or without suction 3
• If lung does not re-expand with water seal alone, apply suction 3
• If no re-expansion after 48-72 hours, verify chest tube position and consider suction 4

Removal Protocol

• Remove chest tube in staged manner to ensure air leak has resolved 1, 3
• Wait 24 hours after cessation of bubbling, then repeat chest x-ray 2
• Confirm resolution with chest radiograph after discontinuing any suction 1
• Withdraw tube while patient holds breath in full inspiration 2

Common Pitfalls

• Never clamp chest tubes - this practice should be avoided 2
• Failure to aspirate may be due to cannula inadvertently withdrawn from pleural cavity or becoming kinked - consider another attempt if suspected 2

Pain Management

• Prescribe adequate oral and intramuscular analgesia throughout treatment 2, 3
• Consider premedication with atropine to prevent vasovagal reaction 2
• For anxious patients, give small dose of intravenous midazolam 2

Follow-Up and Precautions

Hospitalization

• Patients with secondary pneumothorax should remain hospitalized for at least 24 hours after treatment to ensure no recurrence 4

Discharge Instructions

• Arrange chest clinic appointment in 7-10 days 2
• Provide discharge letter and instruct patient to attend immediately if noticeable deterioration occurs 2

Activity Restrictions

• Air travel should be avoided until follow-up radiograph confirms complete resolution (minimum 6 weeks) 4, 1
• Diving should be permanently avoided unless bilateral surgical pleurectomy has been performed 4, 1

Surgical Referral

Indications

• Persistent air leak despite chest tube drainage 4, 5
• Recurrent pneumothorax 4
• Lung fails to re-expand 4

Surgical Options

• Partial pleurectomy has 95% success rate for preventing recurrence 4
• Video-assisted thoracoscopic surgery (VATS) is increasingly preferred over open thoracotomy 2, 6