What is the management of pneumothorax in an intubated (intubated with an endotracheal tube) patient?

Management of Pneumothorax in Intubated Patients

All intubated patients with pneumothorax require immediate chest tube insertion regardless of pneumothorax size, as positive pressure ventilation can rapidly convert a simple pneumothorax into a life-threatening tension pneumothorax. 1

Immediate Chest Tube Placement

Tube Size Selection

• Use a large-bore chest tube (24F-28F) for all mechanically ventilated patients 1
• Large-bore tubes are essential because positive pressure ventilation creates potentially large air leaks that exceed the capacity of smaller tubes 1
• Small-bore tubes (≤14F) are only appropriate for spontaneous pneumothorax in non-ventilated patients and should be avoided in intubated patients 2

Insertion Technique

• Use blunt dissection (for tubes >24F) or Seldinger technique—never use the trocar technique due to risk of organ injury 2
• Image guidance with bedside ultrasonography is preferred when feasible 2
• Full aseptic technique is mandatory to minimize infection risk (empyema occurs in 1-6% of cases) 3

Drainage System Management

Initial Setup

• Connect the chest tube to a water seal device with suction immediately 1
• Use high-volume, low-pressure suction systems (–10 to –20 cm H₂O) 3
• Unlike spontaneous pneumothorax, immediate suction application is preferable in ventilated patients to ensure rapid lung re-expansion and optimize respiratory mechanics 1

Critical Safety Rules

• Never clamp a bubbling chest tube—this can convert a simple pneumothorax into tension pneumothorax 3, 1
• Even non-bubbling tubes should not routinely be clamped in ventilated patients 3
• If clamping is absolutely necessary (under respiratory physician supervision only), the patient must remain in a specialist ward and never leave that environment 3

Monitoring and Ongoing Management

Serial Assessment

• Perform serial chest radiographs to assess pneumothorax resolution and lung re-expansion 4, 1
• Continuous monitoring of respiratory rate, heart rate, blood pressure, and oxygen saturation is essential 4, 1
• Monitor for signs of tension pneumothorax: difficulty bagging, rising peak airway pressures, hypotension, and decreased breath sounds 5, 6

Persistent Air Leak Management

• If air leak persists beyond 48 hours, refer to a respiratory physician 3, 4
• These patients require complex drain management including possible suction adjustment or drain repositioning 3
• If air leak continues beyond 4 days, consider chemical pleurodesis with doxycycline or talc slurry 1
• Surgical intervention (thoracoscopy or limited thoracotomy) may be necessary if conservative management fails 1

Special Considerations for Ventilated Patients

Ventilator Management

• Be aware that positive pressure ventilation, especially with high PEEP, can cause pneumothorax in patients with consolidated, low-compliance lungs 6
• Limit driving pressure and avoid excessive PEEP escalation in non-recruitable lungs 6
• The "baby lung" phenomenon means small areas of functional lung bear most mechanical load, increasing barotrauma risk 6

Common Pitfalls

• Do not delay chest tube placement to pursue other diagnostic interventions 7
• Ultrasound outperforms supine radiography for rapid bedside diagnosis in unstable patients 6
• Ensure proper endotracheal tube position—right mainstem intubation can mimic or complicate pneumothorax 5, 8
• Double-lumen tube insertion carries additional pneumothorax risk and requires careful bronchoscopic confirmation 8

Hospitalization Requirements

• All intubated patients with pneumothorax require ICU-level hospitalization 1, 7
• Management should occur on specialized lung units with experienced medical and nursing staff 3
• Outpatient chest tube management is contraindicated in mechanically ventilated patients (this option exists only for stable, non-ventilated patients with spontaneous pneumothorax) 9