What are the management options for pneumothorax?

Management of Pneumothorax

The management of pneumothorax depends critically on whether it is primary spontaneous, secondary (underlying lung disease), or iatrogenic, with simple aspiration using small-bore catheters (≤14F) as first-line treatment for most cases requiring intervention, while reserving larger chest tubes for patients with COPD, those on positive pressure ventilation, or when aspiration fails. 1

Initial Assessment

When evaluating a patient with pneumothorax, assess:

• Respiratory rate, heart rate, blood pressure, room air oxygen saturation, and ability to speak in complete sentences to determine clinical stability 1
• Size of pneumothorax (small vs. large, typically using 2 cm threshold at the hilum) 2
• Presence of symptoms (chest pain, dyspnea) 2
• Underlying lung disease (particularly COPD or emphysema) 2, 1
• Whether patient is on mechanical ventilation 1

Management Algorithm by Type

Primary Spontaneous Pneumothorax

Small pneumothorax (<2 cm) in asymptomatic patients:

• Observation alone is appropriate 3
• Serial chest radiographs to assess resolution 1

Large pneumothorax (>2 cm) or symptomatic patients:

• Simple aspiration using small-bore catheter (8F) should be attempted first, achieving success in up to 89% of cases 1
• If first aspiration unsuccessful but <2.5 L aspirated, repeat aspiration is reasonable, as over one-third will succeed on second attempt 2
• Catheter aspiration of pneumothorax (CASP) with integral one-way valve systems may reduce need for repeat aspiration 2
• Progress to intercostal tube drainage if aspiration fails 2

Secondary Pneumothorax (Underlying Lung Disease)

Large secondary pneumothoraces (>2 cm), particularly in patients over age 50:

• Tube drainage is recommended as initial treatment due to high risk of failure with simple aspiration 2
• Use 16F-22F chest tube connected to water seal device 1
• Apply suction if lung fails to re-expand with water seal alone 1
• Patients with COPD are more likely to require tube drainage and should not be managed with observation alone 1

Very small secondary pneumothorax (<1 cm or apical) in non-breathless patients:

• Observation may be considered 2

Iatrogenic Pneumothorax

Most iatrogenic pneumothoraces resolve with observation alone 1

When intervention is needed:

• Simple aspiration using small-bore catheter (≤14F) should be first-line treatment 1
• For stable patients without mechanical ventilation, 8F teflon catheter achieves success in up to 89% of cases 1
• Asymptomatic pneumothorax <30% requires only observation with radiographic follow-up 4
• Symptomatic pneumothorax or >30% requires intrathoracic drainage 4

Patients on positive pressure ventilation:

• Require immediate chest drainage—observation is contraindicated 1
• Use 24F-28F large-bore chest tube if anticipated bronchopleural fistula with large air leak or continued positive-pressure ventilation required 1

Chest Tube Management

Critical safety rules:

• A bubbling chest tube should never be clamped 2
• A non-bubbling chest tube should not usually be clamped 2
• If clamping is necessary, must be under supervision of respiratory physician or thoracic surgeon in specialist ward 2
• If patient with clamped drain becomes breathless or develops subcutaneous emphysema, drain must be immediately unclamped 2

Removal:

• Confirm complete pneumothorax resolution and cessation of air leak before removal 1
• Perform chest radiograph to confirm resolution 1

Pain Management

• Intrapleural local anaesthetic (20-25 ml of 1% lignocaine) given as bolus and at 8-hourly intervals significantly reduces pain without affecting blood gas measurements 2
• Adequate oral and intramuscular analgesia throughout treatment 5

Common Pitfalls to Avoid

• Never use sharp metal trocar during tube insertion—associated with major organ penetration (lung, stomach, spleen, liver, heart, great vessels) 2
• Do not use observation alone in mechanically ventilated patients 1
• Do not prematurely remove chest tube before confirming complete resolution 1
• Do not clamp bubbling chest tubes under any circumstances 2
• Consider patient's home circumstances before discharge—some may require admission even with small pneumothorax 2

Special Considerations

• Patients should not travel by air within 6 weeks of pneumothorax resolution 2
• Most significant pneumothoraces detected on chest radiograph 1 hour post-procedure, though occasional delayed presentations occur >24 hours later 2
• Heimlich one-way flutter valve is alternative to underwater seal, allowing outpatient management 2