What is the management of pneumothorax?

Management of Pneumothorax

For tension pneumothorax, perform immediate needle decompression without waiting for imaging; for primary spontaneous pneumothorax, use simple aspiration as first-line treatment; for secondary pneumothorax in patients with underlying lung disease, proceed directly to chest tube drainage. 1, 2

Immediate Life-Threatening Situations

Tension Pneumothorax

• Recognize by cardiorespiratory collapse and treat immediately with needle cannulation in the second intercostal space, mid-clavicular line, without waiting for radiographic confirmation. 1
• This is rare but requires instant intervention to prevent death. 1

Primary Spontaneous Pneumothorax (Healthy Young Adults)

Initial Assessment

• Classify size: small (small rim of air), moderate (lung collapsed halfway to heart border), or complete (airless lung separate from diaphragm). 1
• Assess for significant dyspnea, defined as obvious deterioration in usual exercise tolerance—if present, aspiration is necessary regardless of pneumothorax size. 1

Treatment Algorithm for Primary Pneumothorax

Small pneumothorax without significant symptoms:

• Observation alone with follow-up chest radiography. 1

Moderate to large pneumothorax or symptomatic patients:

• Perform simple aspiration as first-line treatment using a 16-gauge or larger cannula (at least 3 cm long) in the second intercostal space, mid-clavicular line. 1, 2
• Infiltrate local anesthetic down to the pleura before insertion. 1
• Connect cannula to 50 ml syringe via three-way tap and aspirate up to 2.5 liters. 1
• Stop if resistance is felt, patient coughs excessively, or more than 2.5 liters aspirated. 1
• Simple aspiration achieves success in up to 89% of cases without requiring tube drainage. 2

If aspiration fails:

• Insert chest tube (16F-22F) connected to water seal device. 2
• Consider re-aspiration before proceeding to chest tube in selected cases. 1

Secondary Spontaneous Pneumothorax (Underlying Lung Disease)

Key Principle

• Patients with COPD, emphysema, cystic fibrosis, or other chronic lung disease require more aggressive treatment as drainage procedures are less successful and even small pneumothoraces can cause severe respiratory failure. 1, 2

Treatment Algorithm for Secondary Pneumothorax

All patients with underlying lung disease:

• Proceed directly to chest tube drainage (16F-22F) rather than simple aspiration, as aspiration is unlikely to succeed. 2
• Apply suction if lung fails to re-expand with water seal alone. 2
• Observe overnight regardless of treatment method. 1
• Refer to respiratory specialist early, as these patients are more likely to require advanced interventions. 1

Iatrogenic Pneumothorax

Stable Patients Not on Mechanical Ventilation

• Use simple aspiration with small-bore catheter (≤14F or 8F teflon catheter) as first-line treatment. 2
• Success rate up to 89% without requiring tube drainage. 2

Patients on Positive Pressure Ventilation

• Never use observation alone—these patients require immediate chest drainage. 2
• Insert 24F-28F large-bore chest tube if bronchopleural fistula with large air leak anticipated or continued positive-pressure ventilation required. 2

Technical Details for Procedures

Simple Aspiration Technique

• Use second intercostal space, mid-clavicular line (axillary approach is alternative). 1
• French gauge 16 or larger cannula, at least 3 cm long. 1
• May premedicate with atropine to prevent vasovagal reaction; small dose IV midazolam if very anxious. 1
• Repeat chest radiography in inspiration after procedure (expiration film unnecessary). 1

Intercostal Tube Drainage

• Explain procedure throughout and reassure patient. 1
• Consider premedication as above. 1
• Prescribe adequate oral and intramuscular analgesia. 1, 2

Ongoing Management of Chest Tubes

Monitoring

• If lung re-expanded and no bubbling: wait 24 hours, repeat x-ray, then remove drain. 1, 2
• If still bubbling: check chest drain position and patency. 1
• Perform serial chest radiographs to assess resolution and lung re-expansion. 2

Tube Removal

• Remove while patient holds breath in full inspiration. 1
• Use sutures to seal wound. 1

When to Seek Specialist Advice

• Assess why re-expansion not achieved (air leaking around drain site, tube displaced/blocked, large persistent leak). 1
• Consider suction for re-expansion (requires appropriate equipment, pressure settings, experienced nursing staff). 1
• Evaluate need for chemical pleurodesis in certain cases. 1
• Manage surgical emphysema if present. 1

Discharge and Follow-Up

Post-Discharge Instructions

• Arrange chest clinic appointment in 7-10 days. 1, 2
• Instruct patient to return immediately if noticeable deterioration occurs. 1, 2
• Advise avoiding air travel until radiographic changes resolve. 1, 2

Common Pitfalls to Avoid

• Do not clamp chest tubes routinely—this practice should be avoided. 1
• Do not remove chest tube prematurely before confirming complete pneumothorax resolution and cessation of air leak. 2
• If aspiration fails to withdraw air, consider cannula may have been inadvertently withdrawn from pleural cavity or become kinked—attempt re-aspiration. 1
• Do not use observation alone in patients on mechanical ventilation. 2
• Do not underestimate secondary pneumothorax in elderly patients with lung disease—these require aggressive treatment. 1