The main aim of acute treatment of pneumothorax is to rule out tension pneumothorax and to relieve any dyspnoea (1).
Although a common condition, there are considerable worldwide disparities in the management of pneumothorax. e.g. - dividing the pneumothorax into large or small plays an important role in the management recommendation but unfortunately the definition of what constitutes a ‘large’ pneumothorax differs between published guidelines:
- British Thoracic Society (BTS) definition of ‘large’ pneumothorax - >2 cm measurement from the lung margin to chest wall at the level of the hilum
- American College of Chest Physicians (ACCP) definition ‘large’ pneumothorax - ≥3 cm from the lung apex to the thoracic cupola (1)
Patients with pre-existing lung disease tolerate a pneumothorax less well, and the distinction between primary spontaneous pneumothorax (PSP) and secondary spontaneous pneumothorax (SSP) should be made at the time of diagnosis to guide appropriate management (2).
- a diagnosis of secondary spontaneous pneumothorax is made
- if the patient is >50 years and has significant smoking history or
- if there is evidence of underlying lung disease on examination or chest x-ray,
Management of PSP
- in the absence of persistent air leak, PSP will gradually resolve as air is reabsorbed into pulmonary capillaries
- the rate of resolution/reabsorption of spontaneous pneumothoraces has been gauged as being between 1.25% - 2.2% of the volume of the hemithorax every 24 hours in patients treated conservatively (2)
- conservative management
- treatment of choice for small PSP without significant breathlessness
- selected asymptomatic patients with large PSP may also be managed by observation alone
- patients with a small PSP without breathlessness should be considered for discharge with early outpatient review in 2-4 weeks. These patients should also receive clear written advice to return in the event of worsening breathlessness
- supplemental high flow oxygen is recommended when patients are admitted for observation
- active intervention
- patients with significant breathlessness associated with any size of pneumothorax should undergo active intervention
- in large (>2 cm) PSP
- British guidelines recommend needle (14-16G) aspiration (NA)
- NA should not be repeated unless there were technical difficulties
- following failed NA, small-bore (<14 F) chest drain insertion is recommended.
- American guidelines recommend inserting a chest drain or small bore catheter
- a randomized controlled trial reported that success and recurrent rates were similar in both manual aspiration and intercostal drain insertion but manual aspiration was associated with significantly shorter hospital stays
Management of SSP
- air leak is less likely to settle spontaneously hence management involve a more interventional approach because of the increased risk of morbidity, symptoms, and cardiorespiratory compromise
- BTS guidelines recommendations are as follows
- all patients with SSP should be admitted to hospital for at least 24 h and receive supplemental oxygen in compliance with the BTS guidelines on the use of oxygen
- needle aspiration - can be attempted in asymptomatic secondary pneumothorax measuring 1-2 cm at the hilum (American consensus statement suggests that this is not appropriate)
- insertion of a small-bore chest drain -
- early referral to a chest physician is recommended for management of both pneumothorax and underlying lung disease
- those with a persistent air leak should be discussed with a thoracic surgeon at 48 h.
- patients who are unfit for surgery, medical pleurodesis or ambulatory management with the use of a Heimlich valve can be considered
Surgical strategies
- open thoracotomy and pleurectomy - remain the procedure with the lowest recurrence rate (approximately1%) for difficult or recurrent pneumothoraces.
- video-assisted thoracoscopic surgery (VATS) with pleurectomy and pleural abrasion is better tolerated but has a higher recurrence rate of approximately 5%
- surgical chemical pleurodesis - best achieved by using 5 g sterile graded talc, with which the complications of adult respiratory distress syndrome and empyema are rare (2)
Repeat chest X-rays should be taken to assess resolution of pneumothorax.
A bronchopleural fistula is likely if the lung cannot be expanded with the use of a chest drain, or the air leak persists over 5-7 days. They are susceptible to infection and should be sealed surgically.
A tension pneumothorax is a medical emergency.
The British Thoracic Society has published a series of flow diagrams detailing the management of spontaneous pneumothoraces.
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