This document discusses the management of pneumothorax. Key factors in treatment include whether the pneumothorax is spontaneous or traumatic, primary or secondary, the patient's age and symptoms, and the size of the pneumothorax. Small pneumothoraces may be treated with oxygen or simple aspiration while larger ones often require a chest drain. Follow up is important to ensure complete resolution. Recurrent or bilateral pneumothoraces may require early specialist involvement. Treatment options range from observation to procedures like thoracotomy or pleurodesis.

1. Managing Pneumothorax
Dan Stevens

2. Pneumothorax
• Spontaneous or Traumatic
• Primary or Secondary
• Old or Young (patient)
• Breathless or Not
• Big or Small
• Admit or Discharge
• Aspirate or Drain (big or small)

3. 21 Male, sudden pleuritic chest pain,
mild SOB. Fit + Well

5. Spontaneous Pneumothorax
• Why is secondary important
– Increased mortality
– Increased morbidity
• Why size matters
– 2cm cut off has been chosen as compromise between risks of
intervention and length of time to resolution
– 2cm estimated to mean loss of 50% volume of hemithorax
– Rate of resolution = 2% hemithorax in 24 hrs
– Therefore 2cm = 25 days (without leak)

6. ED Treatment Options
• Oxygen
– Decreases time to resolution 4 fold
• Simple aspiration
– 2nd
intercostal space midclavicular line?
• Chest drain
– Small bores recommended (F10-14)
• Better tolerated and no evidence larger is better
– Triangle of safety
– 2nd
intercostal space mid clavicular line in apical

7. Discharge Advice
• Return if SOB
• No flying until complete resolution
– Airlines arbitrarily say at least 6 weeks
– Some say at least 1 week after complete resolution
– Risk of recurrence reduces significantly after 1 year
• Avoid sports until complete resolution
• No scuba diving
– Unless cleared to do so
– Undergone bilateral surgical pleurectomy, has normal lung
function and chest CT
• Stop smoking
– Increased risk of recurrence

8. Follow Up
• All patients should be followed up by a
respiratory physician
• 2 – 4 weeks to ensure complete resolution
• Failure to re-expand within 24 hours with drain
suggests air leak  referral to respiratory
physician
– Suction
– Drain repositioning
• Failure to re-expand at 3-5 days suggests
persistant air leak  Thoracic surgeons

9. 1am, 25 male. L sided chest pain, x1
previous pneumothorax

11. 68 Female. SOB and chest pain. COPD

13. 26 female, 19 weeks pregnant, chest
pain, slight SOB

15. When Else to Involve Specialist Early
• Recurrent pneumothorax (2nd ipsalateral or 1st
contralateral pneumothorax)
• Bilateral pneumothorax
• Professions at risk (Diving, Pilots)
• Pregnancy
– Involvement of obstetrics and thoracic surgeons
early
– High risk recurrence therefore aim to avoid chest
drain

16. 25 male. Fallen off bike. L chest Pain

17. Traumatic Pneumothorax
• Often require treatment with chest drain
• Management of occult pneumothorax
– No lung edge seen on chest x-ray
• Supine
• Small
– Often picked up on CT chest
• Require intervention (drain) if intubation is
required or patient symptomatic
• Can be treated with observation and oxygen

18. Definitive Treatment Options
• Open thoracotomy
• VATS (Video-assisted thoracoscopic surgery)
• Surgical chemical pleurodesis
• Medical pleurodesis
– Less effective

19. Summary
• Spontaneous and traumatic can be treated
similarly
• Patients age, medical state, level of
breathlessness and size of pneumothorax are
main deciding factors
• There are several treatment options
– Can we just leave it to the patient to decide what
they want?