What is the treatment approach for spontaneous pneumothorax?

Treatment of Spontaneous Pneumothorax

Treatment depends on whether the pneumothorax is primary or secondary, the patient's clinical stability, and the size of the pneumothorax, with observation for small asymptomatic cases, simple aspiration or small-bore chest tube for symptomatic primary pneumothorax, and chest tube drainage for most secondary pneumothorax cases. 1, 2

Initial Assessment

Determine three critical factors before proceeding:

• Classify as primary (no underlying lung disease) or secondary (underlying lung disease like COPD) 2, 3
• Assess clinical stability: respiratory rate <24 breaths/min, heart rate 60-120 beats/min, normal blood pressure, room air O2 saturation >90%, and ability to speak in full sentences 4
• Measure pneumothorax size: small is <2 cm rim between lung margin and chest wall (or <3 cm apex-to-cupola distance), large is ≥2 cm (or ≥3 cm) 1, 2

Treatment Algorithm for Primary Spontaneous Pneumothorax

Small Primary Pneumothorax with Minimal Symptoms

• Observation alone is sufficient 1, 2
• Administer high-flow oxygen (10 L/min) to increase reabsorption rate 1, 2
• Instruct patient to return immediately if breathlessness develops 2, 3
• Schedule follow-up chest radiograph after 2 weeks 3

Symptomatic or Large Primary Pneumothorax

• Simple aspiration is first-line treatment with 59-83% success rate 2, 3
• Use a small-bore catheter for aspiration 2
• Success rates are higher in patients under 50 years (70-81%) compared to over 50 years (19-31%) 1
• Repeated aspiration is reasonable if first attempt fails and <2.5 liters were aspirated 3
• If aspiration fails, proceed to intercostal tube drainage using a small-bore catheter (≤14F) or 16F-22F chest tube 4, 2

Unstable Primary Pneumothorax

• Insert 16F-22F chest tube immediately 4, 2
• Attach to water seal device with or without suction 4
• Hospitalize the patient 4
• Reliable patients unwilling to be hospitalized may be discharged with a small-bore catheter attached to Heimlich valve if lung has reexpanded, with follow-up within 2 days 4

Treatment Algorithm for Secondary Spontaneous Pneumothorax

Small Secondary Pneumothorax (<1-2 cm)

• Hospital admission with observation is recommended even for small secondary pneumothorax 1
• Administer high-flow oxygen (10 L/min) with caution in COPD patients 1
• Simple aspiration has poor success rates (19-31% in patients over 50) and is generally not recommended 1, 3

Large Secondary Pneumothorax (>2 cm)

• Immediate intercostal tube drainage is recommended 1, 3
• Use 16F-22F chest tube for stable patients 4
• Use 24F-28F chest tube for unstable patients or those requiring mechanical ventilation 4
• Attach to water seal device with or without suction 4
• Hospitalize for at least 24 hours 3
• 81% of experts recommend intervention to prevent recurrence after the first occurrence of secondary pneumothorax due to potential lethality 4

Special Situations

Tension Pneumothorax

• Immediately insert a cannula of adequate length into the second intercostal space in the mid-clavicular line 1, 3
• Leave in place until a functioning intercostal tube can be positioned 1
• Do not wait for radiographic confirmation 3

Breathless Patients

• Active intervention is required regardless of pneumothorax size 1
• Breathless patients should never be left without intervention 1

Cystic Fibrosis Patients

• Early and aggressive treatment is recommended 1, 3
• Surgical intervention should be considered after the first episode if patient is fit 1, 3
• Partial pleurectomy has 95% success rate 1, 3

Chest Tube Management and Removal

Removal Criteria

• Remove chest tube in staged manner to ensure air leak has resolved 4, 2
• Chest radiograph must demonstrate complete resolution of pneumothorax 4
• Discontinue any suction applied to chest tube 4
• Repeat chest radiograph 5-12 hours after last evidence of air leak 4

Critical Safety Points

• A bubbling chest tube should never be clamped 1
• Non-bubbling chest tubes should generally not be clamped 1
• If clamping is necessary, it should only be under specialist supervision in a dedicated ward 1

Prevention of Recurrence

Surgical Indications

• Medical or surgical thoracoscopy is preferred management for recurrence prevention 4
• Perform staple bullectomy combined with parietal pleurectomy, talc insufflation (poudrage), or parietal pleural abrasion 4
• Parietal pleurectomy or pleural abrasion limited to upper half of hemithorax is preferred 4

Chemical Pleurodesis

• Use when surgery is contraindicated based on patient comorbidities or poor prognosis 4
• Talc slurry has very good consensus as preferred agent 4
• Doxycycline is also acceptable with good consensus 4

Discharge Instructions and Follow-up

• Patients must avoid air travel until follow-up chest radiograph confirms complete resolution (typically 6 weeks) 1, 2, 3
• Diving should be permanently avoided unless bilateral surgical pleurectomy has been performed 2, 3
• Schedule follow-up to ensure complete resolution 1

Common Pitfalls to Avoid

• Do not use sharp metal trocars during intercostal tube drainage as complications including organ penetration are more common 1
• Do not perform pulmonary function tests during acute phase as forced expiratory maneuvers are ill-advised and may produce inaccurate results 4
• Do not underestimate pneumothorax size on plain PA radiograph; CT is most accurate but only recommended in complex cases 1
• Do not refer unstable patients for thoracoscopy without prior stabilization with chest tube 4