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Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum: Treatment & Medication

Author: Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Coauthor(s): Pinaki Mukherji, MD, Assistant Professor, Attending Physician, Department of Emergency Medicine, Montefiore Medical Center
Contributor Information and Disclosures

Updated: Jul 7, 2009

Treatment

Prehospital Care

  • Assess the ABCs, and evaluate the possibility of a tension pneumothorax. Assess the vital signs, and perform pulse oximetry. A tension pneumothorax is almost always associated with hypotension.
  • Administer oxygen to the patient, and establish an intravenous line.
  • Most paramedics are trained to perform needle decompression for immediate relief of a tension pneumothorax.

Emergency Department Care

Immediate attention to the ABCs while assessing vital signs and oxygen saturation is paramount. ED care depends on the hemodynamic stability of the patient. All patients should receive supplemental oxygen to increase oxygen saturation and to enhance the reabsorption of free air. Treatments for primary and secondary spontaneous pneumothorax are the following:

  • Primary spontaneous pneumothorax
    • If the pneumothorax is smaller than 15% (or estimated as small, see Imaging Studies) and the patient is symptomatic but hemodynamically stable, needle aspiration is the treatment of choice.
    • If the pneumothorax is smaller than 15% and if the patient is asymptomatic, many consider observation to be the treatment of choice. (If the patient is admitted, administer oxygen, since this has been shown to speed resolution of the pneumothorax.)
    • If the pneumothorax is greater than 15% (or estimated as large, see Imaging Studies), aspiration using a pigtail catheter left to low suction or water seal is recommended.
  • Secondary spontaneous pneumothorax
    • Tube thoracostomy is the procedure of choice.
    • Pleurodesis decreases the risk of recurrence, as does thoracotomy or video-assisted thoracoscopy to excise the bullae.
  • Iatrogenic pneumothorax: Aspiration is the technique of choice for iatrogenic pneumothoraces because recurrence usually is not a factor. Tube thoracostomy is reserved for very symptomatic patients.
  • Most patients with pneumomediastinum should be admitted and observed for signs of serious complications (eg, pneumothorax, tension pneumothorax, mediastinitis). If the pneumomediastinum occurred from the inhalation of cocaine or smoking of marijuana, observation in the ED for progression may be indicated.

Consultations

Physicians from various services may be needed to care for patients who require tube thoracostomy and admission. A surgeon and a pulmonologist should evaluate patients with recurrent disease to determine the cause and further management.

Medication

The goals of pharmacologic therapy are to reduce symptoms and prevent potential complications.

Anesthetic

Anesthetic agents are used for analgesia in the treatment of sclerotic lesions.


Lidocaine (Dilocaine)

Decreases the permeability to sodium ions in neuronal membranes, resulting in the inhibition of depolarization, and blocking the transmission of nerve impulses. The application of 5% gel is effective in the treatment of painful lesions.

Adult

2-3 mg/kg intrapleurally

Pediatric

Administer as in adults

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; Adams-Stokes syndrome and Wolff-Parkinson-White syndrome; severe sinoatrial, AV, or intraventricular block if no artificial pacemaker is present

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Use a solution without preservatives; caution in heart failure, hepatic disease, hypoxia, hypovolemia or shock, respiratory-depression, and bradycardia; may increase risk of CNS and cardiac adverse effects in elderly patients; high plasma concentrations can cause seizures, heart block, and AV conduction abnormalities

Benzodiazepine

These agents are useful for premedication prior to sclerosis and placement of a thoracostomy tube.


Lorazepam (Ativan)

Sedative hypnotic with short onset of effects and relatively long half-life. Increases the action of GABA, a major inhibitory neurotransmitter in the brain. May depress all levels of the CNS, including the limbic and reticular formations.

Adult

Initial dose: 2 mg total or 0.044 mg/kg IV, whichever is smaller
Alternative: 0.05 mg/kg IV; not to exceed 4 mg/dose

Pediatric

0.05-0.1 mg/kg IV slowly over 2-5 min; may repeat 0.5 mg/kg IV slowly

Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs

Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma

Pregnancy

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

Precautions

Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, Parkinson disease

Analgesic

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


Morphine (Duramorph, MS Contin, Oramorph)

DOC for analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone.

Adult

Initial dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h; IV doses vary; titrate for desired effect

Pediatric

Neonates: 0.05-0.2 mg/kg IV/IM/SC prn
Children: 0.1-0.2 mg/kg IV/IM/SC q2-4h prn
IV doses vary; titrate for desired effect

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects

Documented hypersensitivity; hypotension; potentially compromised airway with uncertain rapid airway control; respiratory depression; nausea; emesis; constipation; urinary retention

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in atrial flutter and other supraventricular tachycardias; vagolytic action may increase ventricular response rate

More on Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum

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References
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Further Reading

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Keywords

pneumothorax, intrapleural air, perivascular alveolar rupture, primary spontaneous pneumothorax, secondary spontaneous pneumothorax, pneumomediastinum, iatrogenic pneumothorax, air in intrapleural space, lung disease, malignant pneumomediastinum, Boerhaave syndrome, cystic fibrosis

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Contributor Information and Disclosures

Author

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.

Coauthor(s)

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.

Medical Editor

Joseph A Salomone III, MD, EMS Medical Director, Kansas City, Missouri; Associate Professor and Staff Physician, Truman Medical Centers/UMKC School of Medicine
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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Paul Blackburn, DO, FACOEP, FACEP, Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona
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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

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.

 
 
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