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.
Local Anesthetics
Class Summary
Local anesthetic agents are used for analgesia for thoracentesis and chest tube placement.
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.
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.
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.
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.
Benzodiazepines
Class Summary
Benzodiazepines are used for conscious sedation. These agents are useful for premedication before pleurodesis/sclerotherapy or placement of a thoracostomy tube.
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.
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.
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.
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.
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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Radiograph of a patient with a small spontaneous primary pneumothorax
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Close radiographic view of patient with a small spontaneous primary pneumothorax (same patient as from the previous image).
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Expiratory radiograph of a patient with a small spontaneous primary pneumothorax (same patient as in the previous images).
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Radiograph of a patient with spontaneous primary pneumothorax due to a left upper lobe bleb.
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Close radiographic view of a patient with spontaneous primary pneumothorax due to a left upper lobe bleb (same patient as in the previous image).
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Radiograph of a patient with a large spontaneous tension pneumothorax.
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Radiograph showing subcutaneous emphysema and pneumothorax.
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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.
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Radiograph of a new left-sided pneumothorax in a patient on mechanical ventilation, requiring high inflation pressures.
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Radiograph of a patient with a complete right-sided pneumothorax due to a stab wound.
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Radiograph of a patient with idiopathic pulmonary fibrosis and a small pneumothorax, following video-assisted thoracoscopic surgery (VATS) lung biopsy.
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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.
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Radiograph depicting a right-sided iatrogenic pneumothorax after transbronchial biopsy.
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Pneumomediastinum from barotrauma may result in tension pneumothorax and obstructive shock.
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Radiograph of a patient in the intensive care unit (ICU) who developed pneumopericardium as a manifestation of barotrauma.
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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.
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Radiograph depicting right main stem intubation that resulted in left-sided tension pneumothorax, right mediastinal shift, deep sulcus sign, and subpulmonic pneumothorax.
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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.
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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.
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Radiograph demonstrating tension and traumatic pneumothorax.
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Radiograph demonstrating tension and traumatic pneumothorax.
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Lateral radiograph demonstrating tension and traumatic pneumothorax.
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Lateral radiograph demonstrating tension and traumatic pneumothorax.
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Chest radiograph depicting tension and traumatic pneumothorax.
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Lateral radiograph depicting tension and traumatic pneumothorax.
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Computed tomography scan demonstrating blebs in a patient with chronic obstructive pulmonary disease (COPD).
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Computed tomography scan demonstrating a bulla in an asymptomatic patient.
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Computed tomography scan demonstrating secondary spontaneous pneumothorax (SSP) from radiation/chemotherapy for lymphoma.
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Computed tomography scan demonstrating emphysematouslike changes (ELCs) in a patient with chronic obstructive pulmonary disease (COPD).
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Computed tomography scan in a patient with a history of bilateral pleurodesis and a strong family history of spontaneous pneumothorax.
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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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Insertion of chest tube. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
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- Overview
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- DDx
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- Treatment
- Approach Considerations
- Treatment Based on Risk Stratification
- Options for Restoring Air-Free Pleural Space
- Prehospital Care
- Hospital Management
- Indications for Surgical Assistance
- Video-Assisted Thoracoscopic Surgery
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- Pleurodesis
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