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CDHB

Spontaneous Pneumothorax

See BTS Guidelines published in Thorax 2010;65 suppl II https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/pleural-disease-guideline/.

Causes of Spontaneous Pneumothorax

• Primary: No known underlying lung disease.
• Secondary: Underlying lung disease such as COPD, acute severe asthma, cystic fibrosis, lymphangioleiomyomatosis.
• Other causes of pneumothorax in general include:
  • Traumatic pneumothorax - these patients should be referred to/discussed with the Cardiothoracic Surgical Service, and
  • Iatrogenic pneumothorax - usually after attempted cannulation of a central vein or after lung or pleural biopsy procedures.

Clinical Signs of Spontaneous Pneumothorax

• Symptoms vary from mild dyspnoea with or without pleuritic chest pain to tension pneumothorax with cardiovascular compromise.
• Signs may include:
  • Reduced chest wall movement on the affected side.
  • Diminished breath sounds on the affected side.
  • Surgical emphysema in the neck or over chest wall.
  • Abnormal deviation of the trachea.

Investigations for Spontaneous Pneumothorax

• CXR - at the bedside if patient unwell.

  Note: The CXR tends to underestimate the size of the pneumothorax

• If the CXR is normal, consider a lateral or lateral decubitus film.
• CT chest is recommended when differentiating a pneumothorax from complex bullous lung disease, when the plain CXR is obscured by surgical emphysema or when aberrant chest tube placement is suspected. A high resolution CT chest may show evidence of underlying parenchymal lung disease.

Treatment

• Discuss case with Respiratory Consultant.
• Treatment is not always required. A small closed pneumothorax in the absence of breathlessness should be managed with observation alone.
• Simple aspiration is recommended for a larger spontaneous pneumothorax without underlying lung disease.
• Simple aspiration is less likely to succeed in secondary pneumothoraces and in this situation is only recommended as an initial treatment in small (= less than 2 cm) pneumothoraces in minimally breathless patients under the age of 50 years. These patients should then be admitted under the Respiratory Service for observation.
• Intercostal tube drainage is recommended in any of the following circumstances:
  • Tension pneumothorax (if life-threatening use a 14G IV cannula in the 2^nd intercostal space anteriorly and place an intercostal tube thereafter).
  • Respiratory compromise.
  • Traumatic pneumothorax.
  • Haemo-pneumothorax.
  • Reaccumulation after a total of >2500 mL removed.
• Technical competence for pleural aspiration or chest drain insertion is essential.
  • As a general rule chest drains are placed in the 'safe triangle', i.e., 5^th or 6^th intercostal space in the anterior axillary line. These can also be placed in the posterior axillary line or in certain situations in the second intercostal space in the anterior mid-clavicular line. Drains for a pneumothorax are directed upwards, to the apical area. Drains for a pleural effusion or haemothorax are directed downwards to the basal area.

    There is no evidence that large chest tubes (>20 French) are generally better than smaller tubes (10-14 French). Smaller tubes will be more comfortable for the patient, however there is a greater risk of kinking or blockages and the airflow (=drainage) rate may prove to be insufficient, in particular in patients with a secondary pneumothorax. Signs of an insufficient or dysfunctional drain include worsening respiratory compromise or surgical emphysema.

    3 way taps must never be used in drains inserted for the management of pneumothorax.

• Inpatient cases with pneumothorax should be managed by either the Respiratory Service on the Respiratory Ward or by the Cardiothoracic Surgical team if traumatic.

Follow-Up

All patients must have a follow-up CXR at 10-14 days to ensure that the pneumothorax has resolved. Smokers must be strongly advised to quit. In recurrent pneumothoraces, a pleurodesis procedure should be considered, and referral to a Respiratory Physician or Thoracic Surgeon is recommended. Advice should be given about air travel (not advised within 2-3 weeks of resolution (Aerospace Medical Association, Air Transport Medicine Committee. Medical guidelines for air travel. Aviat Space Environ Med (2^nd edition 2003)) and scuba diving (contraindicated).

Topic Code: 1678