Managing Pneumothorax

Dan Stevens

Pneumothorax

• Spontaneous or Traumatic• Primary or Secondary• Old or Young (patient)• Breathless or Not• Big or Small• Admit or Discharge• Aspirate or Drain (big or small)

21 Male, sudden pleuritic chest pain, mild SOB. Fit + Well

Spontaneous Pneumothorax

• Why is secondary important– Increased mortality– Increased morbidity

• Why size matters– 2cm cut off has been chosen as compromise between risks of

intervention and length of time to resolution– 2cm estimated to mean loss of 50% volume of hemithorax– Rate of resolution = 2% hemithorax in 24 hrs– Therefore 2cm = 25 days (without leak)

ED Treatment Options

• Oxygen– Decreases time to resolution 4 fold

• Simple aspiration– 2nd intercostal space midclavicular line?

• Chest drain– Small bores recommended (F10-14)

• Better tolerated and no evidence larger is better

– Triangle of safety– 2nd intercostal space mid clavicular line in apical

Discharge Advice• Return if SOB• No flying until complete resolution

– Airlines arbitrarily say at least 6 weeks – Some say at least 1 week after complete resolution– Risk of recurrence reduces significantly after 1 year

• Avoid sports until complete resolution• No scuba diving

– Unless cleared to do so– Undergone bilateral surgical pleurectomy, has normal lung

function and chest CT• Stop smoking

– Increased risk of recurrence

Follow Up• All patients should be followed up by a

respiratory physician• 2 – 4 weeks to ensure complete resolution• Failure to re-expand within 24 hours with drain

suggests air leak referral to respiratory physician– Suction – Drain repositioning

• Failure to re-expand at 3-5 days suggests persistant air leak Thoracic surgeons

1am, 25 male. L sided chest pain, x1 previous pneumothorax

68 Female. SOB and chest pain. COPD

26 female, 19 weeks pregnant, chest pain, slight SOB

When Else to Involve Specialist Early

• Recurrent pneumothorax (2nd ipsalateral or 1st contralateral pneumothorax)

• Bilateral pneumothorax• Professions at risk (Diving, Pilots)• Pregnancy– Involvement of obstetrics and thoracic surgeons

early– High risk recurrence therefore aim to avoid chest

drain

25 male. Fallen off bike. L chest Pain

Traumatic Pneumothorax

• Often require treatment with chest drain• Management of occult pneumothorax– No lung edge seen on chest x-ray• Supine• Small

– Often picked up on CT chest• Require intervention (drain) if intubation is

required or patient symptomatic• Can be treated with observation and oxygen

Definitive Treatment Options

• Open thoracotomy • VATS (Video-assisted thoracoscopic surgery) • Surgical chemical pleurodesis • Medical pleurodesis– Less effective

Summary

• Spontaneous and traumatic can be treated similarly

• Patients age, medical state, level of breathlessness and size of pneumothorax are main deciding factors

• There are several treatment options– Can we just leave it to the patient to decide what

they want?