What is the appropriate high flow oxygen therapy for the treatment of a pneumothorax?

From the Guidelines

For the treatment of a pneumothorax, high-flow oxygen should be administered at a concentration of 100% (or the highest available concentration) via a reservoir mask at a flow rate of 15 L/min, aiming for an oxygen saturation of 94-98% if the patient is not at risk of hypercapnic respiratory failure. This approach is recommended as initial management while preparing for definitive treatment, which typically involves needle decompression or chest tube insertion 1. The high concentration of oxygen helps to increase the rate of pneumothorax resolution by creating a pressure gradient that accelerates nitrogen washout from the pleural space. When blood in the pleural capillaries contains less nitrogen due to high oxygen levels, more nitrogen from the pneumothorax diffuses into the blood, causing the pneumothorax to shrink more rapidly.

Key Considerations

• The use of high-flow oxygen therapy has been shown to result in a four-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation 1.
• Patients should be continuously monitored for respiratory distress, oxygen saturation, and hemodynamic stability while receiving high-flow oxygen therapy.
• Oxygen therapy alone is generally insufficient for tension pneumothorax or large pneumothoraces, which require immediate decompression.
• The recommended oxygen saturation target range is 94-98% for patients with pneumothorax who are not at risk of hypercapnic respiratory failure 1.

Management Approach

• For patients with pneumothorax having hospital observation without drainage, the use of high-concentration oxygen (15 L/min flow rate via reservoir mask) is recommended unless the patient is at risk of hypercapnic respiratory failure 1.
• The addition of high-flow oxygen therapy can help increase the rate of pneumothorax resolution, but it should be used in conjunction with other treatments, such as needle decompression or chest tube insertion, as needed.

From the Research

Treatment of Pneumothorax with High Flow Oxygen

• The use of high flow oxygen for the treatment of pneumothorax has been studied, with evidence suggesting that it can enhance the rate of resolution of pneumothoraces, particularly when smaller than 30% 2.
• A study published in 1983 found that patients with pneumothoraces of less than 30% showed a mean resolution rate of 4.2% per day with reduction to one-third original size in the first 72 hours when treated with a high concentration of inspired oxygen delivered by a partial rebreathing mask 2.
• The administration of high concentrations of inspired oxygen is an effective method to enhance the rate of resolution of pneumothoraces, reducing morbidity and duration of hospitalization and avoiding invasive drainage procedures 2.

Management of Pneumothorax

• The management of pneumothorax is shifting toward more conservative approaches, including the use of lung ultrasound for diagnosis and smaller catheters or observation for treatment 3, 4.
• Recent literature has found that many patients with traumatic pneumothorax can be managed conservatively via observation, or with a smaller thoracostomy such as a percutaneous pigtail catheter rather than a larger chest tube 3, 4.
• Outpatient management of both primary and secondary spontaneous pneumothorax may be safe and feasible, and should be included in treatment options discussion with patients 5.

Dosage of High Flow Oxygen

• The study published in 1983 used a partial rebreathing mask to deliver a high concentration of inspired oxygen, but the exact dosage of oxygen was not specified 2.
• There is no clear consensus on the optimal dosage of high flow oxygen for the treatment of pneumothorax, and further research is needed to determine the most effective treatment protocol.