Determine the following three criteria concerning the diagnosis of a spontaneous pneumothorax. Use an inspiratory CXR (PA, or lateral, if PA is normal and suspicion high). Expiratory CXRs are not recommended:
- Chronic lung disease? (CLD): cystic, fibrotic, bullous or emphysematous lung disease. Patient will be admitted overnight irrespective of treatment.
- Degree of breathlessness? (dyspnoea): ‘Significant means any deterioration in usual exercise tolerance.
- Degree of collapse? (small or large):
- Small: visible rim < 2 cm at level of hilum.
- Large: visible rim ≥ 2 cm (equates to approximately 50% collapse).
This is dictated by absence of CLD (primary pneumothorax) or presence of CLD (secondary pneumothorax); extent of pneumothorax on CXR (large or small); and degree of patient’s breathlessness (dyspnoea) ie. significant or not:
- Non-interventional management:
- Patients without CLD, with no significant dyspnoea and with a small pneumothorax do NOT mandate any treatment at all.
- Aspiration may however be preferred by some to hasten resolution.
- Simple aspiration under LA with 14-16 G cannula, until resistance is felt, patient coughs excessively or over 2.5 litres withdrawn:
- Perform this for a small pneumothorax with significant dyspnoea, in the absence of CLD, or for the majority of large pneumothoraces.
- May be attempted in CLD for a small pneumothorax if under age 50 and minimally dyspnoeic. However, must then admit for 24 hours observation and high-flow oxygen.
- Repeat CXR after aspiration and 6 hours later. If aspiration successful with resolution or only small residual air rim, no evidence continuing air leak and not dyspnoeic, discharge and arrange follow up.
- Aspiration may be repeated if patient is still breathless and less than 2.5 L was aspirated and catheter was blocked or kinked, but ICC insertion is more likely to be needed for this ‘aspiration failure’.
- Aspiration overall is safe and effective for the management of a primary spontaneous pneumothorax, with fewer hospital admissions and, if admitted, a shorter length of stay + appears less painful / less need for analgesia.
- However, small bore chest tube insertion (< 14 F) is now possible and popular using Seldinger technique – see ICC below.
Zehtabchi S, Rios C. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Ann Emerg Med 2008;51:91-100. [Reference]
- Intercostal catheter (ICC) 10 – 14F, using Seldinger technique; or blunt dissection having withdrawn / discarded trocar first. Note if need to replace a smaller ICC, can use a larger 20 -24 F. Small-bore ICC is indicated for:
- Following failed aspiration if patient remains breathless, or if pneumothorax relapses.
- CLD patients with small pneumothorax with dyspnoea or if over 50 yrs, and all large pneumothoraces with CLD.
- Bilateral pneumothorax.
- Remove ICC if stopped bubbling and CXR re-expanded.
- If continues to bubble or pneumothorax fails to re-expand by 48 hrs, consider high-volume low pressure suction system (or look for a kinked tube), and consult respiratory physician.
- Never clamp a bubbling chest tube.
- Indications for surgical advice include second ipsilateral pneumothorax, first contralateral pneumothorax, bilateral synchronous, persistent air leak / failure to expand, spontaneous haemothorax, pregnancy, at-risk profession (pilot / diver).
- Follow up when discharged:
- All patients should be reviewed within 7-10 days by a respiratory physician. Risk of recurrence of spontaneous pneumothorax is up to 54% at 4 years, particularly in smokers, taller patients and age > 60 yr.
- Instruct patient to immediately re-attend Emergency if develops significant dyspnoea or increasing pain.
- Advise those allowed home to stop smoking, avoid extreme exertion, to return if become dyspnoeic, not to fly until at least 1 week after the CXR has returned to normal, and to never SCUBA dive (unless have had bilateral pleurectomies).
Treasure T. Minimal access surgery for pneumothorax. Lancet 2007;370:294-5. [Reference]