Medicine : Spontaneous pneumothorax

Spontaneous pneumothorax

Management guidelines

Introduction

These local guidelines are based on those published by the British Thoracic Society which are evidence-based and have recently been revised [1].

Secondary pneumothorax

See flow chart

This can occur in any patient with asthma, COPD, fibrosing alveolitis or other chronic lung disease. Such patients are less likely to be successfully treated with aspiration alone [2] and are more likely to be symptomatic from small pneumothoraces. They should be observed overnight in all cases. Take care not to confuse apical bullae with pneumothorax.

Degree of collapse

If the rim of air visible on a CXR is > 2cm then the pneumothorax is at least moderate (c. 50% of hemithorax), and requires treatment. Tension pneumothorax = any pneumothorax with cardiorespiratory collapse. Tension pneumothorax is very rare, while rotation of the CXR and apparent mediastinal shift is very common - look carefully.

Significant dyspnoea

Obvious marked deterioration in usual exercise tolerance. Aspiration is necessary in all cases.

Simple aspiration

This is as effective as tube drainage and reduces hospital stay [3].

A sterile procedure - use a dressing pack and povidone iodine/chlorhexidine, gown and sterile gloves.

Infiltrate local anaesthetic in the second intercostal space in the mid-clavicular line.

Use a brown or white venflon attached to a syringe and pass between the ribs in the second ICS until air can be aspirated freely.

Withdraw the needle, then connect a three way tap and 50 ml syringe to the cannula and aspirate air, voiding through the three way tap.

Continue until either (a) resistance is felt, (b) the patient coughs excessively or (c) more than 2.5 litres (50 syringe-fulls) have been aspirated.

Repeat CXR. Procedure is successful if the pneumothorax now small/gone, and the patient's dyspnoea improved.

Repeated aspiration will be successful in about a third of patients who fail first time[].

Inpatient observation

Discharge next day if patient has remained stable. All patients should have high-flow oxygen unless there is concern about hypercapnia, as oxygen speeds the resolution of the pneumothorax [4]. Follow-up and advice as above.

Follow-up

Appointment in chest clinic in two weeks. No air travel until pneumothorax fully resolved and advised in chest unit. No scuba diving ever. Tell patient to contact Dr immediately if significant deterioration in breathing.

Tube drainage

Most young patients can be managed without a drain. Smaller tubes, 10 -14 French gauge are more comfortable and equally effective [5-8] and should be used. Access is via the 4th or 5th intercostal space in the mid-axillary line. The procedure is easier and safer with the patient lying down on the unaffected side, with both arms held up so the hands are in front of or under the face. The sharp point of the drain trocar should not be used to push the drain into the pleural space, though it is permissible to use the trocar to stiffen the drain for insertion provided the trocar is drawn back about a centimetre so that its sharp tip is not exposed.

Tube management

Patient guidance leaflets on the management of chest drains are available from the chest unit, and the respiratory nurse specialist team is happy to advise. The best way of preventing accidental removal of a chest drain is to make the patient responsible for its care and supervision. Drains should never be clamped, because there is no evidence of benefit and there are anecdotal reports of tension pneumothorax developing in this situation [9].

"It don't mean a thing if it ain't got that swing"

If there is no movement of the water meniscus in the underwater seal tube with respiration ("swing"), then the drain is either not patent, or it is not in the pleural space. If the problem cannot be rectified then the drain should be removed. Flushing the drain with air or sterile saline is safe and may remove a fibrin clot or kink in the drain.

Suction

The routine application of suction is not recommended within the first 48 hours of treatment. Suction of large pneumothoraces may precipitate re-expansion pulmonary oedema [10]. Whether it is of benefit in treating a persistent air leak is controversial.

Persistent air leak

If the drain continues to bubble for more than 48 hours, then a persistent air leak (PAL) is present, unless the bubbling is artefactual. Traps for the unwary include air leaking into the drainage system at a poorly fitting connector, or into the pleural space around the drain exit site. These problems are especially common with drains on suction. If a true air leak persists, then specialist referral is necessary (see below).

Referring for specialist advice and management

Patients with a persistent air leak after 48 hours of drainage should be referred to a respiratory physician. Management options include continued tube drainage, with or without suction, medical or thoracoscopic pleurodesis, and thoracic surgical procedures to achieve pleurodesis.

Thoracic surgery

Whether and when to refer the patient for a thoracic surgical opinion is a decision for the respiratory physician and will depend upon several factors including the patient's age and co-morbidity, the severity and prognosis of any underlying lung disease, and the nature and duration of treatment already undertaken. The BTS recommends surgical treatment in:

Second ipsilateral pneumothorax

First contralateral pneumothorax

Bilateral spontaneous pneumothorax

Persistent air leak (tube drainage > 7 days)

Spontaneous haemothorax

Professional divers or pilots

References

This page was last updated: Friday, June 8, 2001 at 3:50:26 PM
Copyright 2009 Chris Bunch

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