eMedicine Specialties > Thoracic Surgery > Trauma

Pneumothorax: Treatment & Medication

Author: 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
Coauthor(s): Michael G Benninghoff, MS, DO, Fellow in Pulmonary and Critical Care Medicine, Penn State Hershey Medical Center; Shoaib Alam, MD, Assistant Professor of Medicine, Division of Pulmonary, Allergy and Critical Care, Pennsylvania State University and Hershey Medical Center
Contributor Information and Disclosures

Updated: Feb 10, 2009

Treatment

Medical Care

Despite large areas of agreement on management of pneumothorax, a full consensus about management of initial or recurrent pneumothorax does not exist. Professional societies differ in their approach to management and hospitalization.25,20

This management section presents a risk stratification framework for choosing among options to restore an air-free pleural space and prevent recurrences.26 While these goals are consistent across diverse clinical presentations, the range of options includes watchful waiting without or with supplemental oxygen, simple aspiration, tube drainage without or with medical pleurodesis, vacuum-assisted thoracostomy (VATS) with pleurodesis and/or closure of leaks and bullectomy, and open surgical procedures such as thoracotomy for pleurectomy or pleurodesis.

Selection among options requires an understanding of the natural history of pneumothorax, the risk of recurrent pneumothorax, and the benefits and limitations of treatment options.

Risk stratification

The decision to observe or to treat with an immediate intervention should be guided by a risk stratification that considers the patient's presentation and the likelihood of spontaneous resolution and recurrence.

  • Patient's presentation
    • Asymptomatic (incidental finding): Treatment decisions are guided by estimate of long-term recurrence risk.
    • Symptomatic but clinically stable: Treatment is guided by local resources and conventions for the site of care. The British Thoracic Society (BTS) advocates for simple aspiration and deferring hospitalization in primary spontaneous pneumothorax (PSP) as initial management if stable.25 A small bore catheter or chest tube placement is recommended by the American College of Chest Physicians (ACCP) Delphi consensus statement.20
    • Clinically fragile: Treatment is guided by local practice patterns for air evacuation and observation. Comorbid conditions may preclude observation because of decreased cardiopulmonary reserve.
    • Life threatening: Pneumothorax that causes hemodynamic instability is life-threatening and must be treated immediately with tube thoracostomy. All documents and recommendations call for intervention if a patient is unstable.
  • Likelihood of resolution
    • Very likely to resolve - Small pneumothorax in a hemodynamically stable patient without significant parenchymal lung disease; small iatrogenic pneumothorax
    • May resolve - Large pneumothorax in a normal lung (eg, PSP or iatrogenic pneumothorax)
    • Unlikely to resolve - Secondary pneumothorax, enlarging pneumothorax (suggests a continuing air leak)
    • Won't resolve, could be fatal - Tension pneumothorax; unrecognized air leak
  • Likelihood of recurrence
    • Unlikely to recur (iatrogenic pneumothorax in normal lung)
    • May recur, but will likely be clinically stable
    • May recur and be clinically unstable but emergency care readily accessible
    • Very likely to recur (diffuse and progressive pulmonary pathology; eg, lymphangioleiomyomatosis [LAM])
    • Recurrence could be life-threatening (poor cardiopulmonary reserve, limited access to emergency medical care)

Selection of site of care

  • Outpatient care: This can occur in asymptomatic patients or those with a small pneumothorax and reliable follow-up.
  • Emergency department (ED) care: ED care is changing. Prolonged periods of observation are less practical because of large patient volumes; efficacy studies of manual aspiration and placement of one-way valves are based in EDs in an attempt to address these practical issues.
  • Inpatient observation: This site of care is generally selected when high-flow oxygen is needed, the pneumothorax is larger but the patient is stable, or comorbidities increase concern about risk or follow-up. The average hospital stay is 2.8 days.
  • ICU: ICU treatment and observation is appropriate for patients who are unstable or intubated.
Interval of observation
  • No protocols regarding serial radiography or imaging exist; the clinician typically reviews serial vital signs and clinical assessments, using the direction and rate of change in the clinical status to select imaging frequency. Monitoring pneumothorax size during this time is important.
    • 0-6 hours: The ACCP Delphi consensus statement recommends observation in an ED for 6 hours, and discharge to home if a follow-up chest radiograph shows no enlargement of the lesion, in reliable patients.20 Emergency room observation with a repeat radiograph 6 hours later used to be common but may be used less often now.
    • 24-96 hours: Additional follow up in 2 days is recommended, with preference given to a 24-48 hour follow-up radiograph in the outpatient setting. Outpatient follow-up during the 96-h (4-d) window is essential to distinguish between a resolved pneumothorax and one that needs evacuation. A CT scan at this time distinguishes between PSP and secondary spontaneous pneumothorax (SSP).
    • 1 month: Full re-expansion can occur, on average, 3 weeks after the initial event.

Options to restore an air-free pleural space

  • Observation without oxygen: Simple observation is appropriate for asymptomatic patients with a minimal pneumothorax (<15-20% by Light's criteria; 2-3 cm from apex to cupola by alternate criteria) with close follow-up, ensuring no enlargement. Air is reabsorbed spontaneously by 1.25% of size pneumothorax per day.27
  • Supplemental oxygen: Oxygen administration at 3 L/min nasal canula or higher flow treats possible hypoxemia and is associated with a 4-fold increase in the rate of pleural air absorption compared with room air alone.
  • Simple aspiration: In an earlier report, simple aspiration in 131 cases of small SP yielded successful results up to 87%.28 Other data describe more limited success in up to 70% cases.29 A more recent ED study supports needle aspiration as safe and effective as chest tube for PSP, conferring the additional benefits of shorter length of stay and fewer hospital admissions.30
  • Aspiration procedure description
    • Prepare the skin with Betadine solution and cover with sterile drapes.
    • Use a 1% Xylocaine solution for local anesthesia.
    • Select the puncture site at the second or third intercostal space in the midclavicular line or in the fourth or fifth intercostal space over the superior rib margin in the anterior axillary line.
    • Place a plastic catheter over the needle into the pleural space.
    • Use a 3-way stopcock and large syringe to evacuate air. When no more air can be aspirated or the patient suddenly coughs, the lung most likely has reexpanded.
    • Remove the catheter, and massage the insertion site with sterile gauze to seal the channel into the pleural space.
    • Obtain a follow-up chest radiograph.
  • Chest tube for air removal: A tube inserted into the pleural space is connected to a device with one-way flow. Examples of such devices are Heimlich valves or water seal canisters, and tubes connected to wall suction devices.
    • Portable system (insertion of a one-way valve): The typical goal of one-way valve systems is to avoid hospital admission and still treat the SP. One-way valves may also expedite hospital discharge and be used during transport of an injured patient. A Heimlich valve allows for complete evacuation of air that is not under tension. Heimlich valves do not require suction and eliminate the chance of a tension pneumothorax; they allow greater mobility and less discomfort for the patient. By decreasing the length of the hospital stay and allowing for outpatient care, medical costs are reduced as well.

      In a pilot study, the efficacy and safety of a serial-steps approach with a single system (small-caliber catheter/Heimlich valve) were evaluated in 41 thin, young, smoking male patients with a first episode of PSP. A one-way Heimlich valve was connected to the catheter, allowing the air to flow spontaneously outward for 24-48 h. Thereafter, if the lung failed to re-expand, wall suction was applied. Patients with an air leak persisting for >4 days were referred for surgery. The 24-h and 1-wk success rates were 61% and 85%, respectively, and the actuarial 1-yr recurrence rate was 24%. When 24-h and 1-wk success rates and recurrence at 12 months were taken as end points, the method described here is as effective as simple manual needle aspiration or a conventional chest tube thoracotomy.31

      Heimlich valves are crucial in the care of patients with AIDS who have a median length of 20 days of chest tube placement.
  • Thoracostomy with continuous (wall) suction: First-time SPS (including COPD) and traumatic pneumothorax typically require this approach. A small-bore catheter (eg, 7-14F) is safe to use in most patients, while a larger chest tube (24F) is also appropriate initially, and increasing suction pressure can be used if the lung fails to come up. A larger tube (eg, 28F) can reduce resistance in patients who are ventilated and at greater risk for air leaks. Air leaks resolve within 7 days of treatment 80% of the time, with an average hospital stay of 5 days. Keep the tube in place for 24 hours after the air leak ceases.

Prevention of recurrent pneumothorax

  • Observation: Observation is appropriate for iatrogenic pneumothorax in an individual with normal lungs who has responded to treatment with observation or simple aspiration. Simple aspiration or chest tube drainage of pneumothorax does not prevent recurrence. Recurrences have been reported to occur in up to 32% of PSP.32,33 A recent study showed that a Heimlich valve with small-caliber catheter was less effective in preventing recurrence than closed thoracostomy. In another study, the recurrence rate after 1 year with Heimlich valve vs. chest tube placement was not significantly different.34 Recurrent spontaneous pneumothorax requires more definitive treatment to prevent recurrence. Recurrence rates are higher with SSP than PSP; hence, observation is less often chosen as an approach in SSP.
  • Pleurodesis: A patient treated with surgical pleurodesis has a recurrence prevention rate of greater than 90%. Talc is the preferred agent for pleurodesis. It can be administered by insufflation or as a slurry. Practice variation depends on local practitioner experience, resources, and success with approaches ranging from video-assisted thoracotomy (recommended by the American College of Chest Physicians)20 to surgical thoracotomy and pleurectomy (recommended by the British Thoracic Society because of the absolute lowest recurrence rates).19
  • Nonsurgical pleurodesis: "Medical" thoracoscopy requires only local anesthesia or conscious sedation, in an endoscopy suite, using nondisposable rigid instruments. Thus, it is considerably less invasive and less expensive, but also less effective, particularly in inexperienced hands. Patient comorbidity plays a role in selection of appropriate intervention. The main diagnostic and therapeutic indications for medical thoracoscopy are pleural effusions and pneumothorax.35
    • Tetracycline and talc are well-studied effective agents for medical pleurodesis; the latter was 5% more effective in 1 randomized study.36 Success rates for chemical are up to 91% vs. 95-100% in surgical techniques.37 Chemical pleurodesis resulted in a significant reduction of recurrence compared to chest tube drainage alone in an early study.38
    • Chemical pleurodesis and surgery were equally effective and were both superior to conservative therapy in preventing the recurrence of pneumothorax in LAM.

Surgical Care

  • Indications for surgical assistance
    • Persistent air leak for more than 7 days
    • Recurrent ipsilateral pneumothorax
    • Contralateral pneumothorax
    • Bilateral pneumothorax
    • First-time presentation in a patient with a high-risk occupation (eg, diver, pilot)
    • Patients with AIDS often need this intervention because of extensive underlying necrosis.
    • The risk of recurrent pneumothorax may also be unacceptable for patients with plans for extended stays at remote sites.
    • Lymphangiomyomatosis, a condition causing a high risk of pneumothorax39
  • Video-assisted thoracoscopic surgery (VATS)
    • VATS is appropriate for recurrent primary spontaneous pneumothorax (PSP) or secondary spontaneous pneumothorax (SSP).
    • VATS with resection of large bullous lesions is associated with a recurrence rate of 2-14%.
    • VATS is done under general anesthesia using a camera and 2 trocar ports.
    • In a meta-analysis of 12 trials that randomized 670 patients, VATS was associated with shorter length of stay (reduction 1.0-4.2 d) and less pain or use of pain medication than thoracotomy in the 5 out of 7 trials in which the technique was used for pneumothorax or minor lung resection. In the treatment of pneumothorax, VATS was associated with substantially fewer recurrences than pleural drainage in 2 trials.40
  • Thoracotomy
    • Insufflation of talc and thoracotomy has a recurrence rate of 0-7%.
    • Recurrence rates are as low as 4%,33 which may be higher than open procedure case series.
    • Talc is the preferred agent for pleurodesis. It can be administered by insufflation or as a slurry.
  • Complications of surgical procedures include the following:
    • Failure to cure the problem
    • Acute respiratory distress or failure
    • Infection of the pleural space
    • Cutaneous or systemic infection
    • Persistent air leak
    • Reexpansion pulmonary edema
    • Prolonged tube drainage and hospital stay
    • Increased risk of post-operative bleeding after lung transplantation (for medical pleurodesis and surgery; not found to affect the length of hospital stay)39

Consultations

  • Consult with a surgeon about patients who require a chest tube, pleurodesis, or surgical thoracotomy and thoracoscopy.
  • If patients have underlying lung disease, thereby increasing the chance of recurrence, consult a pulmonary specialist.
  • Direct patients indicating a readiness to quit smoking to their primary care physician or offer referral for cessation management. This may include nicotine replacement and non-nicotine pharmacotherapy such as bupropion or varenicline.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications. In addition to the medications listed below, 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. Acute respiratory distress syndrome (ARDS) has been reported after use of talc as a pleural sclerosing agent but is considered to be a rare complication.

Local anesthetics

Used for thoracentesis and chest tube placement.


Lidocaine hydrochloride (Xylocaine, Dilocaine, Anestacon)

Local anesthetic used as 1% solution. Onset of action is within 45-90 seconds. Duration of anesthesia is 10-20 min.
Adverse effects with use as local anesthetic include allergic reactions.

Adult

Dose varies with the procedure, local vascularity, and condition of patient; applied locally, not to exceed 4.5 mg/kg; do not repeat within 2 h

Pediatric

Not established

Coadministration with cimetidine or beta-blockers, increases toxicity of lidocaine; coadministration with procainamide and tocainide may result in additive cardiodepressant action; may increase effects of succinylcholine

Documented hypersensitivity to amide-type local anesthetics; avoid in Adams-Stokes syndrome and Wolff-Parkinson-White syndrome; avoid in severe sinoatrial, atrioventricular, or intraventricular block if artificial pacemaker not in place

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

When used as local anesthetic, use proper technique to avoid intravascular administration; have resuscitative equipment available; adjust dose for older population, children, and patients who are critically ill or debilitated

Opiate analgetics

Used for pain control.


Fentanyl citrate (Sublimaze, Fentanyl Oralet)

Onset of analgesia is immediate with IV use. Duration of analgesia is 30-60 min. Respiratory depressant effect may last longer than analgesia.

Adult

0.5-1 mcg/kg/dose IV for minor procedures; may repeat dose at 30- to 60-min intervals

Pediatric

Not established

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants may potentiate adverse effects of fentanyl when both drugs are used concurrently

Documented hypersensitivity, increased intracranial pressure, severe respiratory depression, severe liver or renal insufficiency

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Adjust the dose in renal insufficiency; inject slowly over 3-5 min; rapid IV infusion may cause skeletal muscle rigidity, impaired ventilation, apnea, bronchoconstriction, and laryngospasm


Meperidine hydrochloride (Demerol)

Onset of analgesia occurs within 5 min. Titrate dose to effect. Half-life of the parent drug is 2.5-4 h, prolonged in patients with liver disease. Half-life of the active metabolite, normeperidine, is 15-30 h. Accumulates with high dose and renal insufficiency.

Adult

50-150 mg/dose IV; can repeat in 3-4 h prn

Pediatric

Not established

CYP2D6 enzyme substrate; phenytoin decreases analgesic effect; aggravates adverse effects of isoniazid; MAOIs, serotonin uptake inhibitors, CNS depressants, tricyclic antidepressants, and phenothiazines potentiate effects of meperidine; incompatible with aminophylline, heparin, phenobarbital, phenytoin, and sodium bicarbonate

Documented hypersensitivity; MAOIs taken within the past 14 d

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Use with caution in patients with pulmonary, hepatic, and renal disorders, with increased intracranial pressure, and with seizure disorders; tolerance and drug dependence can develop

Benzodiazepine

Used for conscious sedation.


Midazolam hydrochloride (Versed)

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.

Adult

Initial dose: 0.5-2 mg IV over 2 min; slowly titrate to effect by repeating doses every 2-3 min; usual total dose is 5 mg; decrease initial dose in the older population to 0.5 mg IV; administer no more than 1.5 mg in a 2-min period, to a total dose of 3.5 mg

Pediatric

Not established

Sedative effects of midazolam may be antagonized by theophyllines; narcotics and erythromycin may accentuate sedative effects of midazolam because of decreased clearance

Documented hypersensitivity; cross sensitivity with other benzodiazepines reported; concurrent use of protease inhibitors, eg, amprenavir and ritonavir

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May cause severe respiratory depression/arrest; monitor vital signs, including oximetry per institutional conscious sedation protocols; have appropriate resuscitative equipment available; caution with hepatic or renal impairment, in patients who are older or debilitated; may cause hypotension; causes CNS depression; causes retrograde amnesia; causes dependence and acute withdrawal syndrome

More on Pneumothorax

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Differential Diagnoses & Workup: Pneumothorax
Treatment & Medication: Pneumothorax
Follow-up: Pneumothorax
Multimedia: Pneumothorax
References
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Further Reading

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Keywords

pneumothorax, primary spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP), iatrogenic pneumothorax, traumatic pneumothorax, parenchymal lung disease, apical pleural blebs, chronic obstructive pulmonary disease, COPD, Pneumocystis jiroveci pneumonia, PCP, hemopneumothorax, bronchopleural fistula, transthoracic needle aspiration, therapeutic thoracentesis, pleural biopsy, central venous catheter insertion, transbronchial biopsy, positive pressure mechanical ventilation, inadvertent intubation of the right mainstem bronchus, diagnostic ultrasound

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Contributor Information and Disclosures

Author

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: Nothing to disclose.

Coauthor(s)

Michael G Benninghoff, MS, DO, Fellow in Pulmonary and Critical Care Medicine, Penn State Hershey Medical Center
Michael G Benninghoff, MS, DO 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, Assistant Professor of Medicine, Division of Pulmonary, Allergy and Critical Care, Pennsylvania State University and Hershey Medical Center
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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD, Professor, Department of Surgery, Louisiana State University Health Sciences Center
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.

 
 
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