What are the management options for pneumothorax (collapsed lung)?

Pneumothorax Management

For spontaneous pneumothorax, clinically stable patients with small pneumothoraces should be hospitalized and may be observed or treated with a small-bore chest tube (16F-22F), while large pneumothoraces require chest tube placement; unstable patients of any pneumothorax size require immediate large-bore chest tube (24F-28F) insertion. 1

Initial Assessment

Determine clinical stability by evaluating:

• Respiratory rate, heart rate, blood pressure, and room air oxygen saturation 1, 2
• Ability to speak in complete sentences 2
• Presence of ipsilateral chest pain, dyspnoea, diminished breath sounds, or mediastinal shift 1

Size classification matters: Small vs. large pneumothorax determines initial management approach, though the specific threshold varies by guideline 1.

Management Algorithm by Clinical Scenario

Clinically Stable Patients with Small Pneumothorax

• Hospitalize the patient (observation or simple aspiration in the emergency department without admission is inadequate) 1
• Treatment options include:
  • Observation with serial chest radiographs 1
  • Small-bore chest tube (16F-22F) connected to water seal device 1
  • Simple aspiration using small-bore catheter (≤14F) as first-line for iatrogenic pneumothorax, with success rates up to 89% 2

Critical caveat: Some panel members argue against observation alone due to reports of deaths with this approach 1. When in doubt, favor intervention over observation.

Clinically Stable Patients with Large Pneumothorax

• Place a chest tube (16F-22F) to reexpand the lung and hospitalize 1
• Connect to water seal device with or without suction 1
• Apply suction if lung fails to reexpand with water seal alone 1, 2

Clinically Unstable Patients (Any Size Pneumothorax)

• Immediately place large-bore chest tube (24F-28F) and hospitalize 1
• This includes patients with tension pneumothorax presenting with tachycardia, hypotension, and cyanosis 1

Patients on Mechanical Ventilation

• Use large-bore chest tube (24F-28F) due to risk of large pleural air leaks 1, 3
• Never use observation alone—these patients require immediate chest drainage 2
• Avoid clamping the chest tube in presence of active air leak to prevent tension pneumothorax 3

Iatrogenic Pneumothorax (Post-Procedure)

• Most resolve with observation alone, but when intervention needed, use simple aspiration with small-bore catheter (≤14F) as first-line 2
• Reserve chest tube drainage for:
  • Patients with COPD or underlying lung disease 2
  • Patients on positive pressure ventilation 2
  • Failed aspiration 2

Important timing consideration: Most significant pneumothoraces are detected on chest radiograph 1 hour post-procedure, though occasional delayed pneumothoraces occur beyond 24 hours 1.

Chest Tube Management Details

Size Selection

• Unstable patients or those on mechanical ventilation: 24F-28F 1, 3
• Stable patients without large air leak risk: 16F-22F 1
• Small pneumothoraces or patient preference: ≤14F may be acceptable 1

Connection Options

• Water seal device with or without suction (both acceptable) 1
• Heimlich valve is an alternative allowing outpatient management 1
• If pneumothorax enlarges or surgical emphysema develops with Heimlich valve, switch to underwater seal 1

Ongoing Management

• Perform serial chest radiographs to assess resolution and lung re-expansion 3, 2
• Monitor oxygen saturation and administer oxygen as necessary 1
• Wait 24 hours after bubbling stops before removing chest tube 2
• Ensure complete pneumothorax resolution and cessation of air leak before tube removal 3, 2

Management of Persistent Air Leak

• If air leak persists beyond 4 days, consider chemical pleurodesis 3
• Options include doxycycline or talc slurry for patients who cannot undergo surgery 3
• Surgical intervention (thoracoscopy or limited thoracotomy) may be necessary if conservative management fails 3

Recurrence Prevention

Most experts (81%) recommend intervention after the first secondary pneumothorax due to potential lethality 1. The remaining 19% would intervene after the second occurrence 1.

• Preferred approach: Surgical intervention (medical or surgical thoracoscopy) due to lower recurrence rates 1, 3
• Chemical pleurodesis through chest tube may be used when surgery is contraindicated, based on patient preference, or poor prognosis from underlying disease 1

Special Populations

COPD/Emphysema Patients

• More likely to require tube drainage due to underlying lung disease 2
• Place 16F-22F chest tube connected to water seal, applying suction if lung fails to reexpand 2

Post-Thoracic Surgery or Spontaneous Pneumothorax

• Patients should not travel by air within 6 weeks of resolution 1

Common Pitfalls to Avoid

• Never refer for thoracoscopy without prior stabilization with chest tube 1
• Never use observation alone in mechanically ventilated patients 2
• Never remove chest tube prematurely before confirming complete resolution 3, 2
• Never clamp chest tube with active air leak in ventilated patients 3