Should a chest tube thoracostomy be inserted in a patient with pneumothorax and thyroid storm?

Chest Tube Thoracostomy in Pneumothorax with Thyroid Storm

Yes, chest tube thoracostomy should be inserted in a patient with pneumothorax and thyroid storm, as these patients meet criteria for clinical instability and require immediate chest tube placement regardless of pneumothorax size.

Clinical Reasoning

Defining Clinical Instability in Thyroid Storm

Patients in thyroid storm are by definition clinically unstable based on established pneumothorax management criteria. The American College of Chest Physicians defines an unstable patient as anyone not meeting ALL of the following: respiratory rate <24 breaths/min, heart rate 60-120 beats/min, normal blood pressure, room air oxygen saturation >90%, and ability to speak in whole sentences between breaths 1.

Thyroid storm characteristically presents with:

• Tachycardia (typically >120 bpm, often >140 bpm) 2, 3
• Hyperthermia with temperature instability 2
• Potential hemodynamic instability including hypotension 2
• Risk of cardiac arrest and multiorgan failure 2, 3

These patients cannot meet the stability criteria and therefore fall into the unstable category 1.

Guideline-Based Management for Unstable Patients

Clinically unstable patients with pneumothoraces of any size should undergo placement of a chest tube to reexpand the lung and should be hospitalized (very good consensus) 1. This recommendation applies regardless of pneumothorax size—whether small (<3 cm apex-to-cupola distance) or large (≥3 cm) 1.

Chest Tube Size Selection

For patients with thyroid storm and pneumothorax, tube size should be selected based on:

• 24F to 28F chest tube if the patient requires or is likely to require mechanical ventilation (good consensus), given the risk of large pleural air leaks with positive pressure ventilation 1
• 16F to 22F chest tube may be acceptable if the patient is not requiring mechanical ventilation and clinical instability is primarily from the thyroid storm rather than respiratory compromise 1

Given that thyroid storm patients may deteriorate rapidly and require intubation 2, 3, starting with a larger bore tube (24F-28F) is prudent 1.

Critical Management Considerations

Key pitfalls to avoid:

• Never observe or use simple aspiration alone in unstable patients—this is inappropriate management regardless of pneumothorax size 1
• Never clamp a bubbling chest tube, as this can convert a simple pneumothorax into a life-threatening tension pneumothorax 1
• Do not delay chest tube placement to pursue other diagnostic or therapeutic interventions for the thyroid storm 1

Concurrent Thyroid Storm Management

While chest tube placement is the priority for the pneumothorax, simultaneous management of thyroid storm is essential:

• Standard medical therapy includes beta-blockers, antithyroid drugs, corticosteroids, and iodine 2, 3
• In cases of multiorgan failure with contraindications to standard therapy, continuous renal replacement therapy (CRRT) has been successfully used 2
• The pneumothorax itself may be a precipitating factor for thyroid storm decompensation, making its treatment even more critical 3

Attachment and Monitoring

The chest tube should be attached to a water seal device with or without suction 1. If water seal alone is used initially, suction should be applied if the lung fails to reexpand 1. Given the critical nature of thyroid storm, immediate application of suction may be preferable to ensure rapid lung reexpansion and optimize respiratory mechanics 1.

The patient requires hospitalization in an intensive care setting with continuous monitoring, as thyroid storm carries significant mortality risk, particularly when complicated by respiratory compromise 1, 2, 3.