EBM Spontaneous Pneumothorax

Pedagogical disambiguation: Emergency Medicine Lecture Notes and Evidence Based emergency medicine principles from Professor A.F.T Brown and the Life in the Fast Lane team.

Clinical Appraisal

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).

Management

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aspiration under LA with 14-16 G cannula, until resistance is felt, patient coughs excessively or over 2.5 litres withdrawn: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]

MacDuff A, Arnold A, Harvey J et al. Management of spontaneous pneumothorax: BTS pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii18-ii31.  [Reference] [Website]

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Comments

  1. says

    Can anyone clever explain to me why SIZE of pneumothorax continues to be used to decide whether people treat pneumothorax invasively or not? I have seen no evidence for this, just opinion, and it doesn’t make any sense to me to use pneumothorax size as a nodal point in the choice between drainage (by whatever method) and conservative management.

  2. says

    My understanding is simply that the larger the ptx the longer it takes to reabsorb, and whilst this is happening the more likely it is that the air fails to reabsorb fully due to continued risk of surface blebs blowing etc ie lack of restoration of surface tension and the lung adhering to the chest wall prejudices the likelihood of final full spontaneous resolution…

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