What is the day to day management of a patient with spontaneous pneumothorax?

Day-to-Day Management of Spontaneous Pneumothorax

Initial Classification and Assessment

Classify the pneumothorax as primary (no underlying lung disease) or secondary (underlying lung disease present), assess clinical stability, and measure pneumothorax size to guide treatment decisions. 1

• Evaluate clinical stability by checking respiratory rate, heart rate, blood pressure, oxygen saturation, and ability to speak in full sentences 2
• Measure pneumothorax size on chest radiograph: small is <2-3 cm apex-to-cupola distance, large is ≥3 cm 1, 2
• Symptom severity matters more than size for determining intervention need 3
• Hypoxemia (SpO2 ≤92%) occurs primarily in secondary pneumothorax and older patients (>50 years) with primary pneumothorax 4

Treatment Algorithm for Primary Spontaneous Pneumothorax

Small Pneumothorax with Minimal Symptoms

• Observation alone is sufficient for clinically stable patients with small primary pneumothorax (<2 cm) 1
• Administer high-flow oxygen (10 L/min) if hospitalized to increase reabsorption rate up to four-fold 1, 3
• Instruct patients to return immediately if breathlessness develops 2

Symptomatic or Large Primary Pneumothorax

• Simple aspiration is first-line treatment with success rates of 59-83% 1, 2
• Use a 16-gauge or larger cannula at least 3 cm long in the second intercostal space mid-clavicular line 5
• Discontinue aspiration if resistance is felt, patient coughs excessively, or >2.5 L is aspirated 5
• Repeat aspiration is reasonable if first attempt fails 2
• If aspiration fails, proceed to chest tube drainage using small-bore catheter (≤14F) or moderate-sized tube (16F-22F) 2

Unstable Primary Pneumothorax

• Immediate chest tube insertion (16F-22F) attached to water seal device with or without suction 1

Treatment Algorithm for Secondary Spontaneous Pneumothorax

Small Secondary Pneumothorax (<1-2 cm)

• Hospital admission with observation is mandatory even for small pneumothorax due to potential for rapid deterioration 1
• Administer high-flow oxygen (10 L/min) 1

Large Secondary Pneumothorax (>2 cm)

• Immediate intercostal tube drainage is recommended 1
• Use 16F-22F chest tube for stable patients 1
• Use 24F-28F chest tube for unstable patients or those requiring mechanical ventilation 1
• Consider early surgical intervention after first episode in cystic fibrosis patients if fit 1

Daily Chest Tube Management

Monitoring Air Leak

• Never clamp a bubbling chest tube 2
• For non-bubbling tubes, 41% of experts never clamp; others clamp 5-12 hours after last evidence of air leak 5
• Repeat chest radiograph 13-23 hours after last evidence of air leak before tube removal 5

Persistent Air Leak Management

• Continue observation for 5 days before encouraging surgical intervention in patients initially refusing surgery 5
• Do not apply suction immediately after tube insertion; consider after 48 hours if air leak persists 3
• Use high-volume, low-pressure suction systems (-10 to -20 cm H₂O) if needed 3
• Consider surgery if air leak persists beyond 14 days 3

Staged Chest Tube Removal

• Remove chest tube in staged manner to ensure air leak has resolved 2
• Discontinue suction and confirm resolution with chest radiograph 2
• Withdraw tube while patient holds breath in full inspiration 5
• Prescribe adequate oral and intramuscular analgesia 5

Special Situations

Tension Pneumothorax

• Immediate cannula insertion into second intercostal space mid-clavicular line 1
• Leave in place until functioning intercostal tube can be positioned 1

Breathless Patients

• Active intervention required regardless of pneumothorax size 1

Chronic Lung Disease

• Referral to respiratory specialist is more likely as drainage procedures are less successful 5
• Observe overnight whether or not aspiration was performed 5

Prevention of Recurrence

Indications for Definitive Treatment

• Medical or surgical thoracoscopy is preferred for recurrence prevention 1
• Perform staple bullectomy combined with parietal pleurectomy, talc insufflation, or parietal pleural abrasion 1
• Consider after second ipsilateral or first contralateral pneumothorax 3
• Consider for high-risk professionals (divers, pilots, military personnel) 3

Chemical Pleurodesis

• Use when surgery is contraindicated 1
• Talc slurry (very good consensus) or doxycycline (good consensus) are preferred agents 5, 1
• Instillation through chest tube is appropriate for non-operative candidates 5

Discharge Instructions and Follow-up

Activity Restrictions

• Avoid air travel until follow-up chest radiograph confirms complete resolution (typically 6 weeks) 1, 2
• Diving should be permanently avoided unless bilateral surgical pleurectomy has been performed 1, 2

Follow-up Care

• Schedule follow-up to ensure complete resolution 1
• Provide written discharge instructions to return immediately if breathlessness worsens 5
• Consider recurrence prevention strategies based on patient risk factors 1

Common Pitfalls to Avoid

• Do not use pneumothorax size alone as indication for invasive management; symptom severity is more important 3
• Avoid rapid lung expansion unless absolutely necessary to prevent re-expansion pulmonary edema 6
• Do not delay specialist referral if pneumothorax fails to respond within 48 hours 3
• Small-bore tubes (10-14F) are as effective as large-bore tubes (20-24F) and should be used initially 3
• Complications occur in 11% of patients undergoing drainage, including prolonged air leak (16% primary, 31% secondary) 4