Background

Guidelines reproduced with permission from Thorax 2003;58(Suppl ii):ii39-ii52

  • Primary pneumothaces occur in otherwise healthy people without any lung disease
  • Secondary pneumothoraces arise in subjects with underlying lung disease
  • These guidelines are not for trauma related pneumothoraces
  • Incidence up to 28/100,000 per year
  • Much higher incidence (12% v 0.1% lifetime risk) in smokers
    • Subpleural blebs / bullae likely role in pathogenesis
    • Not related to physical activity
    • Taller individuals (? larger intrapleural pressure gradient)
    • Risk of recurrence 54% in first 4 years
    • No need for expiration CXR
    • Lateral or lateral decubitus film if clinical suspicion high but PA film is normal
    • CT recommended 
      • Differentiate pneumothorax from bullous disease
      • Aberrant tube placement suspected
      • Plain film obscured by surgical emphysema
  • Symptoms associated with 2° pneumothoraces more severe
  • Many patients with 1° pneumothoraces do not seek help for several days (important in re-expansion pulmonary oedema)
  • Plain PA CXR underestimates pneumothorax size
  • Large or small pneumothorax defined by distance between lung margin and chest wall greater or less than 2 cm
    • 2cm gap = 50% pneumothorax by volume

Mx of pneumothorax

Primary pneumothorax occurs in patients who have no clinically apparent lung disorder.

Secondary pneumothorax occurs in patients with an underlying pulmonary disease, most commonly chronic obstructive pulmonary disease (COPD).

Small Pneumothorax: presence of a visible rim of <2 cm between the lung margin and the chest wall.

Large Pneumothorax presence of a visible rim of >2 cm between the lung margin and the chest wall.

General Audit Standards:

  • 90% of patients should be followed according to local policy (but within 2 weeks).
  • 90% of patients should be given written advice on discharge.
  • 100% patients should be referred to a respiratory physician if they fail to respond to treatment within 48 hours as an inpatient.

Primary Spontaneous pneumothorax - minimal symptoms:

  • Small pneumothorax - Aspiration should not be performed
  • Large pneumothorax
    • All should be aspirate
    • All should have a repeat CXR before discharge

Primary Spontaneous pneumothorax - symptomatic:

  • All should have chest aspiration
  • All should have an intercostal drain if aspiration fails.
  • 90% of patients should have intercostal drain of < 14 Gauge.
  • Monitor for REPO

Secondary pneumothorax - minimal symptoms

  • All should be hospitalised.
  • All patients treated successfully with simple aspiration should be admitted to hospital and observed for at least 24 hours.
  • 90% of patients with secondary pneumothorax > or = 2cm depth should have an intercostal drain.

Secondary pneumothorax - symptomatic

  • All should be hospitalised.
  • All should have an intercostal drain before leaving the ED.
  • Monitor for REPO

Primary PTX (NO underlying lung disease)

Flow diagram Management Primary Pneumothorax

Primary pneumothorax
(no underlying lung disease)

  • If suitable and 1st aspiration unsuccessful, then a second attempt at simple aspiration of the pneumothorax should be considered unless >2.5 l was aspirated during the unsuccessful first attempt.
  • Observation is treatment of choice for small (<2cm) closed pneumothoraces without significant breathlessness.
  • Patients with small (<2cm) primary pneumothoraces without breathlessness should be considered for discharge with early out patient follow up. These patient should be given clear written advice to return if worsening breathlessness.
  • If a patient with a pneumothorax is admitted overnight, they should receive high flow , high flow (10 l/min) oxygen should be administered, with appropriate caution in patients with COPD who may be sensitive to higher concentrations of oxygen.
  • Breathless patients should not be left without intervention regardless of the size of the pneumothorax on a chest radiograph

Secondary pneumothorax

(with underlying lung disease)

Management algorithm secondary pneumothorax

Secondary PTX
With underlying lung disease

Strong emphasis should be placed on the relationship between the recurrence of pneumothorax and smoking in an effort to encourage patients to stop smoking.

Seldinger technique chest drain insertion

  • This is the preferred method of drain insertion in spontaneous pneumothorax.
  • Please ask the Duty Doc for supervision.
  • Monitor for REPO

Intercostal tube drainage - (blunt ATLS technique)

Please see Chest Drain section under trauma section. Monitor for REPO