How to manage a patient with Attention Deficit Hyperactivity Disorder (ADHD) who develops a pneumothorax?

Management of Pneumothorax in Patients with ADHD

Manage the pneumothorax according to standard pneumothorax guidelines based on size and clinical stability, while continuing ADHD medications unless the patient requires intubation, in which case stimulants should be temporarily held due to cardiovascular concerns during mechanical ventilation. 1

Pneumothorax Management Takes Priority

The presence of ADHD does not fundamentally alter pneumothorax management strategy. Treatment decisions are based on:

• Clinical stability (respiratory rate <24/min, heart rate 60-120/min, normal BP, room air O2 sat >90%, ability to speak in complete sentences) 1
• Pneumothorax size (small <3 cm apex-to-cupola distance vs large ≥3 cm on upright chest X-ray) 1
• Primary vs secondary pneumothorax (ADHD patients typically have primary spontaneous pneumothorax unless they have underlying lung disease) 1

Treatment Algorithm by Clinical Presentation

For Clinically Stable Patients with Small Pneumothorax (<3 cm):

• Observe in emergency department for 3-6 hours with repeat chest X-ray to exclude progression 1
• Discharge home if stable with follow-up within 12-24 hours for repeat imaging 1
• Simple aspiration or chest tube insertion is not appropriate for most stable patients with small pneumothoraces 1
• Conservative management can be considered for minimally symptomatic or asymptomatic primary spontaneous pneumothorax regardless of size 1

For Clinically Stable Patients with Large Pneumothorax (≥3 cm):

• Insert small-bore catheter (≤14F) or 16-22F chest tube connected to Heimlich valve or water seal device 1
• Hospitalize in most instances 1
• Apply suction if lung fails to reexpand quickly, or apply suction immediately after placement 1

For Clinically Unstable Patients (Any Size):

• Immediately insert 16-22F chest tube connected to water seal device 1, 2
• Hospitalize and monitor continuously 2

ADHD Medication Management During Pneumothorax Treatment

Continue Stimulant Medications in Most Cases:

• ADHD stimulants (methylphenidate, amphetamines) can be safely continued in stable patients not requiring mechanical ventilation 1
• These medications do not increase pneumothorax risk or interfere with standard treatment 1
• Maintaining ADHD treatment helps ensure patient compliance with activity restrictions and follow-up appointments 1

Hold Stimulants if Mechanical Ventilation Required:

• If intubation becomes necessary, temporarily discontinue stimulant medications due to cardiovascular effects (tachycardia, hypertension) that may complicate ventilator management 2
• Insert chest tube (24-28F large-bore) BEFORE initiating positive-pressure ventilation to prevent tension pneumothorax 2

Critical Pitfalls to Avoid

Do Not Assume ADHD Medications Caused the Pneumothorax:

• Primary spontaneous pneumothorax occurs in young, tall, thin individuals (often males) due to rupture of apical blebs 1, 3
• ADHD stimulants are not recognized risk factors for pneumothorax 1
• Smoking is the major modifiable risk factor—assess smoking status in all ADHD patients 3

Ensure Reliable Follow-Up:

• Admit patients for observation if they live distant from emergency services or follow-up is considered unreliable 1
• ADHD patients may have organizational challenges—provide written discharge instructions with specific appointment times 1
• Consider same-day or next-day follow-up rather than 2-day window for patients with adherence concerns 1

Activity Restrictions Are Essential:

• Discharge and activity advice should be given to all patients post-pneumothorax 1
• Avoid air travel until complete resolution documented on chest X-ray 1
• No scuba diving until definitive surgical management performed 1
• Avoid strenuous activity until pneumothorax resolved 1

Recurrence Prevention Considerations

Elective Surgery May Be Indicated:

• Consider elective surgical pleurodesis for second ipsilateral or first contralateral pneumothorax 1
• Video-assisted thoracoscopic surgery (VATS) with pleurodesis and/or bullectomy is the standard approach 1
• Recurrence rates are 33% for primary spontaneous pneumothorax at one year 4

Smoking Cessation Is Critical:

• Smoking cessation reduces risk of future recurrence in active smokers 3
• Address smoking cessation aggressively in ADHD patients, as smoking rates are higher in this population 3

Special Monitoring Considerations

• Monitor for signs of tension pneumothorax: severe respiratory distress, hypotension, tracheal deviation, absent breath sounds 2, 5
• Serial chest X-rays to document lung re-expansion and resolution 1, 2
• Do not remove chest tube until lung fully re-expanded and air leak completely resolved 2