Management of Pneumothorax
The management of pneumothorax depends critically on three factors: clinical stability, pneumothorax size, and whether it is primary or secondary to underlying lung disease, with treatment ranging from observation with high-flow oxygen to immediate chest tube placement. 1
Initial Assessment
Determine the following key parameters immediately:
- Clinical stability: Patient is stable if respiratory rate <24 breaths/min, heart rate 60-120 beats/min, normal blood pressure, room air oxygen saturation >90%, and can speak in complete sentences 2
- Pneumothorax size: Small if <3 cm apex-to-cupola distance on upright chest radiograph; large if ≥3 cm 2, 1
- Type: Primary (no underlying lung disease) versus secondary (underlying COPD or other lung disease) 2
Treatment Algorithm by Clinical Scenario
Primary Spontaneous Pneumothorax
Small pneumothorax (<3 cm) in stable patients:
- Observation alone is acceptable if minimally symptomatic 1
- Administer high-flow oxygen at 10 L/min to accelerate reabsorption up to four times faster 3, 1
- Simple aspiration should be attempted first if symptomatic, with success rates of 59-83% 1
- If aspiration fails, place a small-bore catheter (≤14F) or 16F-22F chest tube 2, 1
Large pneumothorax (≥3 cm) in stable patients:
- Place chest tube (16F-22F preferred) and hospitalize 2
- Attach to water seal device with or without suction initially 2
- Apply suction if lung fails to reexpand with water seal alone 2
Any size pneumothorax in unstable patients:
- Immediate chest tube placement (16F-22F for most; 24F-28F if large air leak anticipated or mechanical ventilation required) 2
- Hospitalize and attach to water seal with suction 2
Secondary Spontaneous Pneumothorax (COPD or other lung disease)
All secondary pneumothoraces require more aggressive management due to potential lethality: 2
Small pneumothorax (<3 cm) in stable patients:
- Hospitalize (observation or chest tube based on symptoms and clinical course) 2
- Do NOT manage with simple aspiration or discharge from emergency department 2
- High-flow oxygen at 10 L/min 3
Large pneumothorax (≥3 cm) in stable patients:
- Place 16F-22F chest tube and hospitalize 2
- Small-bore catheter (≤14F) acceptable only for small pneumothoraces with patient preference 2
Unstable patients (any size):
- Immediate 24F-28F chest tube if mechanically ventilated or large air leak expected 2
- 16F-22F chest tube acceptable for stable patients without large air leak risk 2
Chest Tube Management
- Water seal device preferred over Heimlich valve for most hospitalized patients 2
- Start with water seal without suction; add suction if lung fails to reexpand 2
- Remove chest tube only after confirming air leak resolution and lung reexpansion on chest radiograph 1
Recurrence Prevention
For secondary pneumothorax, 81% of experts recommend intervention after first occurrence due to high mortality risk: 2
- Surgical intervention preferred (thoracoscopy or muscle-sparing thoracotomy) with staple bullectomy plus pleural symphysis procedure 2
- Acceptable pleural symphysis methods: parietal pleurectomy, talc poudrage, or parietal pleural abrasion (limited to upper hemithorax) 2
- Chemical pleurodesis through chest tube (talc slurry or doxycycline) reserved for surgical contraindications or poor prognosis 2
Follow-up and Restrictions
- Chest radiograph at 2-4 weeks post-discharge to confirm complete resolution 3
- Avoid air travel until radiographic resolution confirmed (typically 6 weeks) 3, 1
- Permanent diving restriction unless bilateral surgical pleurectomy performed 1
Critical Pitfalls to Avoid
- Do NOT perform simple aspiration for secondary pneumothorax—these patients require chest tube placement 2
- Do NOT refer unstable patients directly to thoracoscopy without chest tube stabilization first 2
- Do NOT use chest tubes larger than 28F—they provide no additional benefit 2
- Do NOT discharge secondary pneumothorax patients from emergency department, even if small—hospitalization mandatory 2