What are the treatment guidelines for pneumothorax?

Treatment guidelines for pneumothorax:

In 2010, the British Thoracic Society (BTS) published their updated guidelines for the management of spontaneous pneumothorax. Here, the spontaneous pneumothorax was divided into 2 categories:
  • Primary pneumothorax: No evidence of overt lung disease; air escapes from the lung into the pleural space through rupture of a small pleural bleb or the pulmonary end of a pleural adhesion
  • Secondary pneumothorax: Underlying lung disease, most commonly COPD and tuberculosis; also seen in asthma, lung abscess, pulmonary infarcts, lung cancer and all forms of fibrotic and cystic lung disease
The Depth of pneumothorax (image)
Depth of pneumothorax

[Depth of pneumothorax; source

Treatment of primary pneumothorax:

▪︎If the rim of air is < 2cm and the patient is not short of breath, then discharge should be considered and review in the outpatient clinic in 2-4 weeks
▪︎If the rim of air is > 2cm and/or the patient is breathless, aspiration should be attempted
▪︎If this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted.
▪︎If, following aspiration the rim of air is < 2cm and the breathing has improved then discharge should be considered with outpatient review in 2-4 weeks.

Inter-pleural distance to size of pneumothorax(image)

Pneumothorax conversion from cm to percentage
[Rim of air (in cm) to approx size of pneumothorax (in percentage)]

Treatment of secondary pneumothorax:

▪︎If the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
▪︎Aspiration should be attempted if the rim of air is between 1-2cm. If successful (post aspiration rim size < 1 cm), the patient should be admitted, given high flow oxygen (unless suspected oxygen-sensitive) and observed for at least 24 hours. If aspiration fails (i.e. pneumothorax is still greater than 1cm) a chest drain should be inserted. 
▪︎If the pneumothorax is less the 1cm then the BTS guidelines suggest giving high flow oxygen (unless suspected oxygen-sensitive) and admitting for 24 hours.

Pneumothorax management flow-chart (image)
Management of spontaneous pneumothorax
[Management of spontaneous pneumothorax (from here)]

The BTS guidelines for diving and air travel in the post pneumothorax period:

● Scuba diving: Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively
● Air travel: It is acceptable once the pneumothorax has fully resolved. A patient should only air travel at least 2 weeks after the complete aspiration of the air and confirmed full inflation of the lung

Aspiration Vs Chest drain 

■ The aspiration is done in the second intercostal space anteriorly in the mid-clavicular line using a 16 F cannula. It needs to be discontinued if-
• Resistance is felt
• The patient coughs excessively, or 
• More than 2.5 L of air is removed

■ Intercostal chest drains are inserted in the fourth, fifth or sixth intercostal space in the mid-axillary line, connected to an underwater seal or one-way Heimlich valve. The drain should be removed the morning after the lung has fully re-inflated and the bubbling has stopped. Continued bubbling after 5–7 days is an indication for surgery. If bubbling in the drainage bottle stops before full re-inflation, the tube is either blocked or kinked or displaced

• Davidson's Principles and Practice of Medicine; 23rd Edition; page: 625
• Step Up To MRCP Review Note For Part I & Part II By Dr Khaled El Magraby; page: 215

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