Life in the Fast Lane

SPONTANEOUS PNEUMOTHORAX

CLINICAL APPRAISAL

Determine the following three criteria concerning the diagnosis of a spontaneous pneumothorax. Use an inspiratory CXR (PA, or lateral, if PA is normal and suspicion high). Expiratory CXRs are no longer recommended:

• Chronic lung disease (CLD) ?: cystic, fibrotic, bullous or emphysematous lung disease. Patient will be admitted overnight irrespective of treatment.
• Degree of collapse ? (now only considered small or large):
  • Small: visible rim < 2cm.
  • Large: visible rim > or equal to 2 cm.
• Degree of breathlessness (dyspnoea) ?: Significant means any deterioration in usual exercise tolerance.

MANAGEMENT

This is dictated by absence of CLD (primary pneumothorax) or presence of CLD (secondary pneumothorax); extent of pneumothorax on CXR (large or small); and degree of patient’s breathlessness (dyspnoea) ie. significant or not:

Non-interventional management:

• Patients without CLD, with no significant dyspnoea and with a small pneumothorax do not mandate ANY treatment at all.
• Aspiration may however be preferred by some to hasten resolution.

Simple aspiration under LA,

Aspiration continued until resistance is felt, patient coughs excessively or over 2.5 litres withdrawn:

• Perform this for a small pneumothorax with significant dyspnoea, in the absence of CLD, or for all large pneumothoraces.
• May be attempted in CLD for a small pneumothorax if under age 50 and minimally dyspnoeic. Admit all for 24 hours observation.
• Repeat CXR after aspiration and 6 hours later. If aspiration successful with resolution or only small residual air rim, no evidence continuing air leak and not dyspnoeic, discharge and arrange repeat CXR within next 24 hours.
• Aspiration may be repeated if patient is still breathless and less than 2.5 L was aspirated.
• Aspiration is as safe and effective as tube thoracostomy for the management of a primary spontaneous pneumothorax, with fewer hospital admissions and, if admitted, a shorter length of stay + appears less painful / less need for analgesia.

Zehtabchi S, Rios c. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Ann Emerg Med 2008;51:91-100. [Reference]

Noppena M, De Keukeleire T. Pneumothorax Respiration 2008;76:121-127 [Reference]

Intercostal catheter (ICC)

Using blunt dissection technique having withdrawn / discarded trocar first.  Use 10 - 14F, unless persistent air leak and need to replace a smaller ICC, when can use a larger 20 -24F. ICC is indicated for:

• Following failed aspiration if patient remains breathless, or if pneumothorax relapses.
• CLD patients with small pneumothorax with dyspnoea or if over 50, and all large pneumothoraces with CLD.
• Bilateral pneumothorax.
• Remove ICC if stopped bubbling and CXR re-expanded.  If continues to bubble or pneumothorax fails to re-expand, consider suction or a kinked tube, and consult respiratory physician by 48 hours. Never clamp a bubbling chest tube.

Follow up when discharged:

• All patients should be reviewed within 7-10 days by a respiratory physician. One third will recur, but after 2 pneumothoraces 50% recur, and after 3 pneumothoraces 70% will recur.

Treasure T. Minimal access surgery for pneumothorax. Lancet 2007;370:294-5. [Reference]

• Instruct patient to immediately re-attend Emergency if develops significant dyspnoea or increasing pain.
• Advise those allowed home to avoid exertion especially Valsalva manoeuvre, to return if become dyspnoeic, not to fly until at least 4 weeks after the CXR has returned to normal, and to never SCUBA dive (unless have had bilateral pleurectomies).

Henry M, Arnold T et al. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003; 58 (Suppl II): ii39-ii52 [Reference] . www.brit-thoracic.org.uk/