Hand Percussion in Pneumothorax
Hand percussion (chest physiotherapy/chest percussion) is NOT specifically contraindicated in patients with pneumothorax, though certain airway clearance therapies that generate positive pressure should be avoided. The available guidelines address airway clearance therapies broadly but do not identify traditional manual chest percussion as a contraindication.
Evidence-Based Approach to Airway Clearance in Pneumothorax
Small Pneumothorax
- Airway clearance therapy in general should NOT be stopped for patients with small pneumothorax 1.
- The rationale is that airway obstruction from retained secretions may actually worsen the pneumothorax 1.
- No specific recommendation was made against most traditional airway clearance modalities including manual chest percussion for small pneumothorax 1.
Large Pneumothorax
- Consider withholding airway clearance therapies in patients with large pneumothorax in many circumstances 1.
- However, if a chest tube is present, withholding therapies may not be necessary 1.
Specific Therapies to AVOID in Pneumothorax
The following airway clearance modalities should NOT be used in patients with pneumothorax:
- Positive Expiratory Pressure (PEP) and Oscillating PEP (oPEP) - should be withheld in both small and large pneumothorax 1.
- Intrapulmonary Percussive Ventilation - should not be used in patients with pneumothorax 1.
- BiPAP or positive pressure ventilation - should be withheld from all patients with pneumothorax regardless of size, as positive pressure may cause progression or enlargement 2.
Key Distinction
The concern with these modalities is the positive pressure they generate, which can worsen pneumothorax 2. Traditional manual chest percussion does not generate sustained positive intrathoracic pressure in the same manner.
Therapies That Should CONTINUE
- Aerosol therapies should NOT be stopped in patients with pneumothorax, regardless of pneumothorax size or aerosol type 1.
Important Clinical Caveats
Diagnostic vs. Therapeutic Percussion
- Diagnostic percussion (tapping the chest to assess for pneumothorax) is a valid and useful clinical tool 3, 4.
- Sternal percussion with simultaneous auscultation can diagnose pneumothorax with an exaggerated, resonant, booming quality on the affected side 4.
- This diagnostic technique should not be confused with therapeutic chest physiotherapy percussion 3, 4.
Post-Resolution Considerations
- After pneumothorax resolution, avoid flying for 2-6 weeks 1.
- Avoid weight lifting for a period after resolution 1.
- Withhold spirometry for 2 weeks after resolution 1.
Critical Safety Point
- Never clamp a bubbling chest tube as this can convert a simple pneumothorax into a life-threatening tension pneumothorax 1.
- If a chest tube must be clamped (non-bubbling), this should only occur under specialist supervision in a monitored ward setting 1.
Practical Algorithm
For patients with active pneumothorax:
- Immediately discontinue PEP/oPEP and intrapulmonary percussive ventilation 1
- Discontinue BiPAP or any positive pressure ventilation 2
- Continue aerosol therapies 1
- For small pneumothorax: continue most other airway clearance including traditional manual percussion 1
- For large pneumothorax: consider withholding airway clearance therapies unless chest tube is in place 1