Management of Pneumothorax
Pneumothorax is defined as air in the pleural space - that is, between the lung and the chest wall. Primary spontaneous pneumothoraces arise in otherwise healthy people without any lung disease. Secondary spontaneous pneumothoraces arise in subjects with underlying lung disease. By definition, there is no apparent precipitating event in either.
Assessment / monitoring
- In both primary and secondary spontaneous pneumothoraces the diagnosis is usually established by plain chest radiography. (Expiratory chest radiographs are not recommended for the routine diagnosis of pneumothorax).
- A lateral chest or lateral decubitus radiograph should be performed if the clinical suspicion of pneumothorax is high, but a CXR is normal.
- CT scanning is recommended when differentiating a pneumothorax from complex bullous lung disease, when aberrant tube placement is suspected, and when the plain chest radiograph is obscured by surgical emphysema.
- The clinical history is not a reliable indicator of pneumothorax size.
- The flow diagrams for primary and secondary pneumothoraces provide a systematic approach to treatment decisions.
- Remember that breathless patients should not be left without intervention regardless of pneumothorax size on chest radiograph.
- There is no evidence that large chest drains are more effective except in trauma. Smaller drains (e.g. ≤ 16 Fr) are easier to insert and better tolerated by the patient.
- Ideally patients with chest drains should be managed in a ward used to dealing with them (e.g. respiratory ward) to minimise complications.
- Further treatment options include chest drain suction, chemical pleurodesis and thoracic surgery. If a pneumothorax fails to respond to treatment within 48 hours, prompt referral to a respiratory physician is essential so that these options may be considered.
- Persons with a second or recurrent pneumothorax should be referred for a respiratory opinion as pleurodesis and investigation for underlying lung disease may be indicated.
- Patients should be advised that they should not fly until the pneumothorax has resolved radiologically and for 6 weeks afterwards. They should further be advised to seek specialist medical advice prior to scuba-diving as this may be permanently contraindicated.
Strong emphasis should be placed on the relationship between the recurrence of pneumothorax and smoking in an effort to encourage patients to stop smoking.
Reproduced from Thorax (MacDuff A, Arnold A, Harvey J, on behalf of the BTS Pleural Disease Guideline Group, 65 (Suppl 2): ii18-ii31, 2010) with permission from BMJ Publishing Group Ltd.