What is the management and treatment of pneumothorax?

Management and Treatment of Pneumothorax

For clinically stable patients with small pneumothoraces (<3 cm apex-to-cupola distance), observe for 3-6 hours in the emergency department with repeat chest radiograph, then discharge home if no progression is seen, avoiding chest tube placement in most cases. 1

Initial Assessment and Classification

Determine clinical stability using these specific criteria 1:

• Stable patient: respiratory rate <24 breaths/min, heart rate 60-120 beats/min, normal blood pressure, room air oxygen saturation >90%, and ability to speak in complete sentences between breaths
• Unstable patient: any deviation from the above parameters

Classify pneumothorax size by measuring the distance from lung apex to ipsilateral thoracic cupola on upright chest radiograph 1:

• Small: <3 cm apex-to-cupola distance
• Large: ≥3 cm apex-to-cupola distance

Distinguish between primary (no underlying lung disease) and secondary pneumothorax (underlying lung disease present, especially COPD), as secondary pneumothoraces require more aggressive treatment 1, 2

Treatment Algorithm for Spontaneous Pneumothorax

Small Pneumothorax in Stable Patients

• Observe in emergency department for 3-6 hours 1
• Obtain repeat chest radiograph to exclude progression 1
• Discharge home if stable with follow-up in 12 hours to 2 days 1
• Simple aspiration or chest tube insertion is inappropriate for most patients unless the pneumothorax enlarges 1
• Admit patients who live distant from emergency services or have unreliable follow-up 1

Large Pneumothorax in Stable Patients

Primary pneumothorax: Simple aspiration using a small-bore catheter (≤14F or 8F teflon catheter) achieves success in up to 89% of cases and should be first-line treatment 3

Secondary pneumothorax: Even small pneumothoraces require chest tube drainage as first-line treatment due to underlying lung disease 2

Chest Tube Selection by Clinical Scenario

The American College of Chest Physicians consensus provides specific guidance on chest tube sizing 1:

For stable patients not on mechanical ventilation (all sizes rated as appropriate):

• Small-bore chest tube (≤14F): appropriate first-line option
• 16-22F: appropriate option
• 30-36F: appropriate option

For patients with COPD or secondary pneumothorax: Place 16-22F chest tube connected to water seal device; apply suction if lung fails to re-expand with water seal alone 3

For patients on positive pressure ventilation: Use 24-28F large-bore chest tube if bronchopleural fistula with large air leak is anticipated or continued positive-pressure ventilation is required 3

Iatrogenic Pneumothorax

Most iatrogenic pneumothoraces resolve with observation alone 3. When intervention is needed:

• First-line: Simple aspiration using small-bore catheter (≤14F) 3
• Reserve chest tube drainage for: patients with COPD, those on positive pressure ventilation, or when aspiration fails 3
• Critical pitfall: Never use observation alone in patients on mechanical ventilation—they require immediate chest drainage 3

Tension Pneumothorax

For hemodynamic instability or severe respiratory distress 2, 4:

• Immediate needle decompression using large-bore cannula
• Follow promptly with tube thoracostomy
• Clinical diagnosis may necessitate immediate intervention before imaging confirmation in critically ill patients 4

Management of Persistent Air Leak

If the lung does not re-expand 2:

• Verify chest tube position
• Consider suction if no re-expansion after 48-72 hours
• Wait 24 hours after bubbling stops before removing chest tube 3

Special Populations

Cystic Fibrosis

• Early and aggressive treatment is recommended 1
• Surgical intervention should be considered after the first episode if patient is fit for procedure 1
• Partial pleurectomy has 95% success rate 1, 2
• Recurrence rate with observation or tube thoracostomy alone is unacceptably high at 50% 1

AIDS/HIV with PCP

• Associated with severe necrotising alveolitis and refractory air leaks 1
• Higher hospital mortality, 40% bilateral pneumothoraces, and more prolonged air leaks 1
• Occurrence of pneumothorax is considered an indicator for treatment of active P. carinii infection 1

Crack Users

• Treat as secondary pneumothorax with aggressive management due to high recurrence risk 2
• Even small pneumothoraces require chest tube drainage as first-line treatment 2
• Remain hospitalized for at least 24 hours after treatment to ensure no recurrence 2

Prevention of Recurrence

For recurrent pneumothorax, consider early surgical intervention 2:

• Partial pleurectomy has 95% success rate 2
• Chemical pleurodesis through chest tube is an alternative 1
• Note: Sclerosants can make future lung transplantation more difficult 1

Discharge Instructions and Follow-Up

Primary Pneumothorax

• Successfully treated patients should be observed to ensure clinical stability before discharge 1
• Follow-up chest radiograph after 2 weeks 1

Secondary Pneumothorax

• Admit for 24 hours after successful simple aspiration before discharge to ensure no recurrence 1, 2

Activity Restrictions

• Avoid air travel until chest radiograph confirms complete resolution (minimum 6 weeks) 1, 2
• Permanently avoid diving unless bilateral surgical pleurectomy has been performed 1, 2
• Provide written instructions to return immediately if noticeable deterioration occurs 3

Common Pitfalls to Avoid

• Do not use observation alone in mechanically ventilated patients 3
• Do not remove chest tube prematurely before confirming complete pneumothorax resolution and cessation of air leak 3
• Do not underestimate small pneumothoraces in patients with underlying lung disease—they require more aggressive treatment 2
• Even small, asymptomatic pneumothoraces can rapidly progress to tension pneumothorax when positive pressure ventilation is initiated 4