Pneumothorax Medication

  • Author: Brian James Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Feb 24, 2012
 

Medication Summary

A tension pneumothorax requires treatment with rapidity. However, anesthetics and analgesics should be used if the patient is not in distress. The goals of pharmacotherapy are to reduce morbidity and to prevent complications. In addition to the medications discussed in this section, talc may be used as a sclerosing agent for pleurodesis by mixing 2-5 g in 250 mL of sterile isotonic sodium chloride solution to form a slurry or poudrage. Note that acute respiratory distress syndrome (ARDS) has been reported after use of talc as a pleural sclerosing agent, but this is considered a rare complication.

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Local Anesthetics

Class Summary

Local anesthetic agents are used for analgesia for thoracentesis and chest tube placement.

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Lidocaine hydrochloride (Xylocaine, LidaMantle, Anestacon)

 

Lidocaine hydrochloride is a local anesthetic that may be absorbed following topical administration to mucous membranes. Its rate and extent of absorption depends on the specific site of application, duration of exposure, concentration, and total dosage. This drug acts by decreasing the permeability to sodium ions in neuronal membranes, resulting in the inhibition of depolarization, and blocking the transmission of nerve impulses. Adverse effects with the use of lidocaine hydrochloride as a local anesthetic include allergic reactions.

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Opiate Analgesics

Class Summary

Opiate analgesic agents are used for pain control, which is essential to good patient care, ensures patient comfort, and promotes pulmonary toilet. Most analgesics have sedating properties, which are beneficial for patients with painful skin lesions. These drugs are important in the initial placement of thoracostomy tubes and for controlling pain after the procedure.

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Fentanyl citrate (Sublimaze)

 

The onset of analgesia with fentanyl citrate is immediate with intravenous (IV) administration, and the duration of analgesia is 30-60 minutes. However, the respiratory depressant effect may last longer than analgesia. The dose should be individualized, and vital signs should be monitored in routinely.

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Morphine (Astramorph, Infumorph 200, MS Contin, Oramorph SR)

 

Morphine is the drug of choice for analgesia because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone.

In adults, the initial dose is given intravenously and titrated for effect. Recommended doses begin at 0.1 mg/kg, but practically the regimen is 1-2 mg IV. The dose may be repeated at frequent intervals until analgesia is reached, and then the interval is lengthened. For most adults, the usual upper limit during the acute event is 10-15 mg over the first 4 hours. Morphine IV, delivered via patient-controlled analgesia machines, is set to get 1-2 mg on demand every 6 minutes, with a 4-hour lockout of 30 mg. Conversion to oral narcotics is accomplished as soon as possible.

In neonates, the dose is 0.05-0.2 mg/kg IV/IM/SC as needed; in children, the dose is 0.1-0.2 mg/kg IV/IM/SC q2-4h as needed. As in adults, the IV doses vary and the drug should be titrated for the desired effect.

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Benzodiazepines

Class Summary

Benzodiazepines are used for conscious sedation. These agents are useful for premedication before pleurodesis/sclerotherapy or placement of a thoracostomy tube.

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Midazolam

 

Benzodiazepine used for sedation component of conscious sedation protocol. Onset of action occurs within 1-5 min. Half-life of 1-4 h. Prolonged with liver cirrhosis, congestive heart failure, obesity, and old age.

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Lorazepam (Ativan)

 

Lorazepam is a sedative hypnotic with a short onset of effects and a relatively long half-life. This drug acts by increasing the action of gamma aminobutyric acid (GABA), a major inhibitory neurotransmitter in the brain. However, lorazepam may depress all levels of the central nervous system (CNS), including the limbic and reticular formations.

The initial adult dose is 2 mg total or 0.044 mg/kg IV, whichever is smaller. Alternatively, administer 0.05 mg/kg IV, not to exceed 4 mg/dose.

In children, the dose is 0.05-0.1 mg/kg IV slowly over 2-5 minutes; a slow 0.5 mg/kg IV dose may be repeated.

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Antibiotics

Class Summary

In patients with repeated pneumothoraces who are not good candidates for surgery, pleurodesis (or sclerotherapy) may be necessary. Two major sclerosing agents that can be used are talc and doxycycline. Prophylactic antibiotics are not recommended for the placement of chest tubes in nontraumatic causes.

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Doxycycline (Vibramycin, Vibra-Tabs, Doryx)

 

Doxycycline is broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. It is almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations.

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Cefazolin (Kefzol)

 

Cefazolin is a first-generation cephalosporin. According to the Eastern Association for the Surgery of Trauma (EAST) Practice guidelines, a first-generation cephalosporin should be administered for no longer than 24 hours after tube thoracostomy.

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Contributor Information and Disclosures
Author

Brian James Daley, MD, MBA, FACS, FCCP, CNSC  Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Shabir Bhimji, MD, PhD  Locum Cardiothoracic and Vascular Surgeon, Saudi Arabia and Middle East Hospitals

Shabir Bhimji, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Chest Physicians, American Lung Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Rebecca Bascom, MD, MPH  Professor of Medicine, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Pennsylvania State College of Medicine, Milton S Hershey Medical Center; Graduate Faculty Member, Pennsylvania State University College of Medicine and The Huck Institutes of the Life Sciences

Rebecca Bascom, MD, MPH is a member of the following medical societies: American College of Chest Physicians, American Public Health Association, American Thoracic Society, and Pennsylvania Thoracic Society

Disclosure: Pfizer Ownership interest Other; Teva Pharmaceuticals Ownership interest Other; Bristol Myers Squibb Ownership interest None; Broncus, Inc Consulting fee Consulting

Michael G Benninghoff, DO, MS  Attending Physician in Pulmonary and Critical Care Medicine, Christiana Medical Center

Michael G Benninghoff, DO, MS is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Osteopathic Association, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Shoaib Alam, MD  Staff Clinician, Pulmonary and Vascular Medicine, National Heart, Lung, and Blood Institute, National Institutes of Health

Shoaib Alam, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, European Respiratory Society, International Society for Magnetic Resonance in Medicine, Pennsylvania Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD  Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

Additional Contributors

Erik D Barton, MD, MS Associate Director, Assistant Professor, Department of Surgery, Division of Emergency Medicine, University of Utah Health Sciences Center

Erik D Barton, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Marc D Basson, MD, PhD, MBA, FACS Professor, Chair, Department of Surgery, Assistant Dean for Faculty Development in Research, Michigan State University College of Human Medicine

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, and Sigma Xi

Disclosure: Nothing to disclose.

H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine and Biosciences

H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, andWilderness Medical Society

Disclosure: Nothing to disclose.

Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

Jeffrey Glenn Bowman, MD, MS Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

Andrew K Chang, MD Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center

Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

Tunc Iyriboz, MD Chief, Division of Clinical Image Management, Assistant Professor, Department of Radiology, Hershey Medical Center, Pennsylvania State University

Tunc Iyriboz, MD is a member of the following medical societies: American College of Radiology, American Medical Association, and Radiological Society of North America

Disclosure: Nothing to disclose.

Seema Jain Pennsylvania State University College of Medicine

Disclosure: Nothing to disclose.

Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Pinaki Mukherji, MD Assistant Professor, Attending Physician, Department of Emergency Medicine, Montefiore Medical Center

Pinaki Mukherji, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Benson B Roe, MD Emeritus Chief, Division of Cardiothoracic Surgery, Emeritus Professor, Department of Surgery, University of California at San Francisco Medical Center

Benson B Roe, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, American Society for Artificial Internal Organs, American Surgical Association, California Medical Association, Society for Vascular Surgery, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Joseph A Salomone III, MD Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Daniel S Schwartz, MD, FACS Assistant Clinical Professor of Cardiothoracic Surgery, Mount Sinai School of Medicine; Chief of Thoracic Surgery, Huntington Hospital

Daniel S Schwartz, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Society of Thoracic Surgeons, and Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Milos Tucakovic, MD Fellow, Department of Internal Medicine, Sections of Pulmonary Disease, Allergy and Critical Care Medicine, Milton S Hershey Medical Center, Pennsylvania State College of Medicine

Milos Tucakovic, MD is a member of the following medical societies: American College of Physicians and American Medical Association

Disclosure: Nothing to disclose.

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Radiograph of a patient with a small spontaneous primary pneumothorax
Close radiographic view of patient with a small spontaneous primary pneumothorax (same patient as from the previous image).
Expiratory radiograph of a patient with a small spontaneous primary pneumothorax (same patient as in the previous images).
Radiograph of a patient with spontaneous primary pneumothorax due to a left upper lobe bleb.
Close radiographic view of a patient with spontaneous primary pneumothorax due to a left upper lobe bleb (Same patient as in the previous image).
Radiograph of a patient with a large spontaneous tension pneumothorax.
Radiograph showing subcutaneous emphysema and pneumothorax.
This chest radiograph has 2 abnormalities: (1) tension pneumothorax and (2) potentially life-saving intervention delayed while waiting for x-ray results. Tension pneumothorax is a clinical diagnosis requiring emergent needle decompression, and therapy should never be delayed for x-ray confirmation.
Radiograph of a new left-sided pneumothorax in a patient on mechanical ventilation, requiring high inflation pressures.
Radiograph of a patient with a complete right-sided pneumothorax due to a stab wound.
Radiograph of a patient with idiopathic pulmonary fibrosis and a small pneumothorax, following video-assisted thoracoscopic surgery (VATS) lung biopsy.
Close radiographic view of a small pneumothorax in a patient with idiopathic pulmonary fibrosis, following video-assisted thoracoscopic surgery (VATS) lung biopsy (same patient as in the previous image). Note that the hole on a chest tube is outside the pleural space.
Radiograph depicting a right-sided iatrogenic pneumothorax after transbronchial biopsy.
Pneumomediastinum from barotrauma may result in tension pneumothorax and obstructive shock.
Radiograph of a patient in the intensive care unit (ICU) who developed pneumopericardium as a manifestation of barotrauma.
Radiograph of an older man who was admitted to the intensive care unit (ICU) postoperatively. Note the right-sided pneumothorax induced by the incorrectly positioned small-bowel feeding tube in the right-sided bronchial tree. Marked depression of the right hemidiaphragm is noted, and mediastinal shift is to the left side, suggestive of tension pneumothorax. The endotracheal tube is in a good position.
Radiograph depicting right main stem intubation that resulted in left-sided tension pneumothorax, right mediastinal shift, deep sulcus sign, and subpulmonic pneumothorax.
This is a chest radiograph of an elderly male with chronic obstructive pulmonary disease who presented with a second left-sided spontaneous pneumothorax in 2 months. Chest thoracostomy was performed, the patient was admitted, and talc pleurodesis was performed the next day.
This chest radiograph shows pneumomediastinum (radiolucency noted around the left heart border) in this patient who had a respiratory and circulatory arrest in the emergency department after experiencing multiple episodes of vomiting and a rigid abdomen. The patient was taken immediately to the operating room, where a large rupture of the esophagus was repaired.
Radiograph demonstrating tension and traumatic pneumothorax.
Radiograph demonstrating tension and traumatic pneumothorax.
Lateral radiograph demonstrating tension and traumatic pneumothorax.
Lateral radiograph demonstrating tension and traumatic pneumothorax.
Chest radiograph depicting tension and traumatic pneumothorax.
Lateral radiograph depicting tension and traumatic pneumothorax.
Computed tomography scan demonstrating blebs in a patient with chronic obstructive pulmonary disease (COPD).
Computed tomography scan demonstrating a bulla in an asymptomatic patient.
Computed tomography scan demonstrating secondary spontaneous pneumothorax (SSP) from radiation/chemotherapy for lymphoma.
Computed tomography scan demonstrating emphysematouslike changes (ELCs) in a patient with chronic obstructive pulmonary disease (COPD).
Computed tomography scan in a patient with a history of bilateral pleurodesis and a strong family history of spontaneous pneumothorax.
Illustration depicting multiple fractures of the left upper chest wall. The first rib is often fractured posteriorly (black arrows). If multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black lines) may result, which may result in pneumothorax.
 
 
 
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