What is the management of pneumothorax?

Management of Pneumothorax

The management of pneumothorax depends critically on whether it is primary or secondary, the size of the pneumothorax, and the patient's clinical stability—with tension pneumothorax requiring immediate needle decompression, while stable primary pneumothorax can often be managed with simple aspiration rather than chest tube drainage. 1

Immediate Recognition and Emergency Management

Tension Pneumothorax

• Requires immediate needle cannulation without waiting for imaging confirmation if there is cardiorespiratory collapse, as this is a life-threatening emergency. 1
• Insert a large-bore cannula in the second intercostal space, mid-clavicular line, to decompress immediately. 1
• Follow with formal chest tube placement after initial decompression. 2

Classification by Size and Symptoms

The British Thoracic Society defines pneumothorax size as: 1

• Small: Small rim of air around lung
• Moderate: Lung collapsed halfway towards heart border
• Complete: Airless lung, separate from diaphragm

Significant dyspnea (obvious deterioration in usual exercise tolerance) mandates aspiration regardless of pneumothorax size. 1

Primary Spontaneous Pneumothorax Management

Small, Asymptomatic Pneumothorax

• Observation alone is appropriate for clinically stable patients with minimal symptoms and small pneumothoraces. 3, 4
• Repeat chest radiography to confirm stability. 1

Large or Symptomatic Primary Pneumothorax

• Simple aspiration should be the first-line intervention, as it is quick, well-tolerated by patients, and successful in up to 89% of cases. 1, 2

Aspiration Technique: 1

• Infiltrate local anesthetic down to the pleura in the second intercostal space, mid-clavicular line (axillary approach is alternative)
• Use a cannula ≥16 French gauge and ≥3 cm long
• Enter pleural cavity, withdraw needle, connect cannula to 50 mL syringe via three-way tap
• Discontinue if resistance felt, excessive coughing occurs, or >2.5 L aspirated 1
• Obtain post-procedure chest X-ray in inspiration (expiration film unnecessary) 1

Failed Aspiration

• If aspiration fails (pneumothorax remains large), proceed to small-bore chest tube (16F-22F) connected to water seal device. 2
• Consider re-aspiration as an option before proceeding to chest tube. 1
• Small catheter kits with Seldinger technique and Heimlich valves are gaining popularity as alternatives. 1

Secondary Spontaneous Pneumothorax Management

Secondary pneumothorax occurs in patients with underlying lung disease (COPD, emphysema, cystic fibrosis, bullous disease) and requires more aggressive management due to poor respiratory reserve. 1, 5

Initial Approach

• Even small secondary pneumothoraces typically require chest tube drainage as first-line treatment rather than simple aspiration, as drainage procedures are less successful in diseased lungs. 1, 2
• All patients with secondary pneumothorax must be observed overnight regardless of treatment method. 1

Chest Tube Management

• Place 16F-22F chest tube connected to water seal for patients with COPD. 2
• Apply suction if lung fails to re-expand with water seal alone. 2
• Wait 24 hours after bubbling stops before removing the drain. 1, 2
• Remove tube while patient holds breath in full inspiration. 1

When to Refer to Respiratory Specialist

• Early specialist referral is indicated for: 1
  • Failure of lung re-expansion
  • Persistent air leak
  • Need for suction management
  • Consideration of chemical pleurodesis
  • Management of surgical emphysema

Iatrogenic Pneumothorax

Most iatrogenic pneumothoraces resolve with observation alone, but when intervention is needed, simple aspiration using small-bore catheter (≤14F) should be first-line treatment. 2

Exceptions Requiring Immediate Chest Tube

• Patients on positive pressure ventilation require immediate chest drainage (24F-28F large-bore tube)—observation alone is contraindicated. 2
• Patients with COPD are more likely to require tube drainage. 2
• Anticipated bronchopleural fistula with large air leak. 2

Recurrence Prevention

Indications for Definitive Treatment

• Definitive pleurodesis is recommended after first recurrence of primary pneumothorax. 4
• Secondary pneumothorax should undergo pleurodesis after first episode to minimize recurrence risk. 4
• Surgical pleurodesis (partial pleurectomy) has 95% success rate. 5

Critical Pitfalls to Avoid

• Never clamp chest tubes routinely—this practice should be questioned and documented if performed. 1
• Do not remove chest tube prematurely—confirm complete resolution and cessation of air leak first. 2
• Never use observation alone in mechanically ventilated patients—they require immediate drainage. 2
• Failure to aspirate may indicate cannula withdrawal from pleural cavity or kinking—consider repeat attempt. 1

Post-Procedure Care and Follow-Up

• Prescribe adequate oral and intramuscular analgesia as chest tubes are uncomfortable and sometimes very painful. 1
• Arrange chest clinic appointment in 7-10 days. 1, 2
• Advise patients to avoid air travel until radiographic changes resolve (minimum 6 weeks). 1, 5
• Instruct patients to return immediately if noticeable deterioration occurs. 1, 2
• Patients should permanently avoid diving unless bilateral surgical pleurectomy performed. 5

Monitoring During Treatment

• Continuously monitor respiratory rate, heart rate, blood pressure, and oxygen saturation. 2
• Perform serial chest radiographs to assess resolution and lung re-expansion. 2
• If lung does not re-expand after 48-72 hours, verify chest tube position and consider suction. 5