What is the treatment for a patient with a history of smoking who develops a large pneumothorax?

Treatment of Large Pneumothorax in a Patient with Smoking History

A patient with a smoking history who develops a large pneumothorax should be classified as having secondary spontaneous pneumothorax and requires chest tube drainage (16F-22F) with hospitalization in virtually all cases. 1

Classification and Risk Stratification

This patient falls into the secondary spontaneous pneumothorax (SSP) category based on two key factors:

• Smoking history automatically classifies patients as SSP, particularly if >50 years of age with significant smoking exposure 1
• Patients with smoking history have underlying emphysema-like lung changes that increase risk of complications and recurrence 1, 2
• Large pneumothorax is defined as ≥3 cm distance from lung apex to thoracic cupola on upright chest X-ray 1

Immediate Management Algorithm

Step 1: Assess Clinical Stability

Determine if the patient meets ALL of the following stability criteria 1:

• Respiratory rate <24 breaths/min
• Heart rate >60 and <120 beats/min
• Normal blood pressure
• Room air oxygen saturation >90%
• Ability to speak in complete sentences between breaths

Any patient not meeting all criteria is unstable and requires immediate aggressive intervention. 1, 2

Step 2: Chest Tube Insertion (Primary Treatment)

For clinically stable patients with large SSP:

• Insert a 16F-22F chest tube (moderate-sized) as first-line treatment 1
• Small-bore catheters (≤14F) may be acceptable in highly selected stable cases, though there is concern for occlusion risk 1
• Hospitalization is mandatory - observation alone or simple aspiration is inappropriate for large SSP 1

For clinically unstable patients:

• Immediately insert 16F-22F chest tube for most patients 1
• Use 24F-28F large-bore tube if patient requires mechanical ventilation or has anticipated large air leak 1
• Never delay for imaging if tension pneumothorax is suspected clinically 3, 4

Step 3: Drainage System Selection

Connect the chest tube to either 1:

• Water seal device (preferred for most hospitalized patients) - can be used with or without suction initially 1
• Heimlich valve (acceptable alternative, particularly for ambulatory management in highly reliable stable patients) 1

Apply suction if the lung fails to reexpand with water seal alone. 1

Critical Management Pitfalls to Avoid

Mechanical Ventilation Considerations

If the patient requires intubation and positive-pressure ventilation, a chest tube MUST be inserted BEFORE initiating ventilation to prevent tension pneumothorax. 2, 4 Use a 24F-28F tube in this scenario. 1

Why Simple Aspiration is Inappropriate

• The British Thoracic Society explicitly states that needle aspiration has significant limitations in secondary pneumothorax and should not be used as primary treatment 1, 2
• Patients with underlying lung disease (including smoking-related changes) have poor lung reserve and higher failure rates with aspiration 1
• The 2023 BTS guidelines represent a major shift from older practices, emphasizing chest tube drainage over aspiration for SSP 1

Ongoing Management and Monitoring

Chest tube removal criteria (all must be met) 1:

• Complete resolution of pneumothorax on chest X-ray
• No clinical evidence of ongoing air leak
• Discontinue suction first, then observe for 5-12 hours before removal 1

Follow-up requirements 1:

• Repeat chest X-ray at 2-4 weeks to confirm complete resolution
• Counsel on smoking cessation (reduces recurrence risk) 1
• Advise no commercial air travel until 7 days after radiographic resolution 1
• Permanently discourage scuba diving unless definitive surgical pleurodesis performed 1

Recurrence Prevention

Most experts (81%) recommend intervention to prevent recurrence after the FIRST episode of SSP due to the potential lethality in patients with underlying lung disease 1. Options include:

• Surgical intervention (video-assisted thoracoscopic surgery with pleurodesis ± bullectomy) is preferred and should be strongly considered 1
• Chemical pleurodesis through chest tube is an acceptable alternative for patients with contraindications to surgery or poor prognosis 1
• Elective surgery should definitely be considered after a second ipsilateral or first contralateral pneumothorax 1

Evidence Quality and Guideline Divergence

The 2023 British Thoracic Society guidelines 1 represent the most current evidence and show substantial evolution from the 2001 American College of Chest Physicians consensus 1. However, both agree on the fundamental principle: large secondary pneumothorax requires chest tube drainage with hospitalization. The key difference is that newer guidelines allow more patient choice in primary spontaneous pneumothorax, but this flexibility does NOT apply to secondary pneumothorax in smokers. 1