What is the treatment for a collapsed lung (pneumothorax)?

Treatment of Collapsed Lung (Pneumothorax)

For primary spontaneous pneumothorax requiring intervention, simple aspiration is the first-line treatment, while secondary pneumothorax typically requires chest tube drainage except in small (<2 cm), minimally symptomatic cases in patients under 50 years. 1

Immediate Assessment and Stabilization

Tension Pneumothorax Recognition

• Any pneumothorax with cardiorespiratory collapse requires immediate needle decompression without waiting for imaging confirmation 1
• Marked breathlessness with a small (<2 cm) pneumothorax may herald tension and requires urgent intervention 1

Size Classification

• Small: <2 cm rim of air at the lung apex 1
• Moderate: lung collapsed halfway toward heart border 1
• Complete: airless lung, separate from diaphragm 1

Treatment Algorithm by Clinical Presentation

Primary Pneumothorax (No Underlying Lung Disease)

Small pneumothorax without significant dyspnea:

• Observation with high-flow oxygen (10 L/min) is appropriate for discharge with early outpatient follow-up 1
• Oxygen therapy accelerates reabsorption four-fold compared to room air 1
• Natural reabsorption occurs at 1.25-1.8% of hemithorax volume per 24 hours, meaning a 15% pneumothorax takes 8-12 days to resolve 1

Any size pneumothorax with significant dyspnea:

• Simple aspiration is first-line treatment with 59-83% success rate 1
• Perform in second intercostal space, mid-clavicular line using ≥16 French gauge cannula 1
• Aspirate up to 2.5 liters; stop if resistance felt or excessive coughing occurs 1
• Success rates are higher when <3 liters aspirated (89% vs. no success with >3 liters) 1

Failed aspiration:

• Insert chest tube with water-seal drainage 1
• Consider premedication with atropine to prevent vasovagal reaction; midazolam for anxiety 1
• Remove tube 13-23 hours after air leak ceases with confirmatory chest X-ray 1

Secondary Pneumothorax (Underlying Lung Disease Present)

Critical distinction: Secondary pneumothorax patients tolerate collapse poorly and require more aggressive management 1

Small (<1 cm) pneumothorax, asymptomatic:

• Hospitalize for observation with high-flow oxygen (10 L/min) 1
• All patients require overnight observation regardless of intervention 1

Small (<2 cm) pneumothorax, minimal symptoms, age <50:

• Simple aspiration may be attempted but has only 33-67% success rate (vs. 59-83% in primary) 1
• Hospitalize for minimum 24 hours even if aspiration successful 1

All other secondary pneumothoraces:

• Chest tube drainage is required as first-line treatment 1
• Aspiration success drops to 19-31% in patients >50 years and 27-67% with chronic lung disease 1
• Refer to respiratory specialist early as drainage procedures are less successful in emphysematous, bullous, fibrotic, or cystic lung disease 1

Technical Considerations

Simple Aspiration Technique

• Use local anesthesia down to pleura 1
• Connect cannula to 50 mL Luer-lock syringe via three-way tap 1
• Discontinue if >2.5 liters aspirated, resistance felt, or excessive coughing 1
• Obtain post-procedure inspiratory chest X-ray (expiratory films unnecessary) 1

Chest Tube Management

• Provide adequate oral and intramuscular analgesia as tubes are uncomfortable and often painful 1
• Wait 24 hours after bubbling stops before removal 1
• Remove during full inspiration breath-hold 1

Persistent Air Leak Management

• Chemical pleurodesis with talc or doxycycline for non-operative candidates 1
• Surgical referral if air leak persists beyond expected timeframe 1

Discharge and Follow-up

• Schedule chest clinic appointment 7-10 days post-discharge 1
• Prohibit air travel until radiographic resolution confirmed (typically 6 weeks) 1
• Instruct patients to return immediately if symptoms worsen 1

Key Pitfalls to Avoid

The American College of Chest Physicians differs from British guidelines: ACCP found simple aspiration appropriate "rarely in any clinical circumstance," preferring chest tube drainage 1. However, the more recent 2003 BTS guidelines demonstrate Level A evidence that simple aspiration is as effective as tube drainage for primary pneumothorax with lower hospitalization rates and fewer recurrences 1.

Common technical errors:

• Failure to aspirate may indicate cannula withdrawal from pleural cavity or kinking—attempt repositioning before declaring failure 1
• Using expiratory chest X-rays (unnecessary and may overestimate size) 1
• Discharging secondary pneumothorax patients without 24-hour observation 1