What are the treatment guidelines for pneumothorax?

Treatment guidelines for pneumothorax:

In 2010, the British Thoracic Society (BTS) published their updated guidelines for the management of spontaneous pneumothorax. Here, the spontaneous pneumothorax was divided into 2 categories:

• Primary pneumothorax: No evidence of overt lung disease; air escapes from the lung into the pleural space through rupture of a small pleural bleb or the pulmonary end of a pleural adhesion
• Secondary pneumothorax: Underlying lung disease, most commonly COPD and tuberculosis; also seen in asthma, lung abscess, pulmonary infarcts, lung cancer and all forms of fibrotic and cystic lung disease

The Depth of pneumothorax (image)

[Depth of pneumothorax; source] 

Treatment of primary pneumothorax:

• If the rim of air is < 2cm and the patient is not short of breath, then discharge should be considered and review in the outpatient clinic in 2-4 weeks.
• If the rim of air is > 2cm and/or the patient is breathless, aspiration should be attempted.
• If this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted.     
• If, following aspiration the rim of air is < 2cm and the breathing has improved then discharge should be considered with outpatient review in 2-4 weeks.

Inter-pleural distance to the size of pneumothorax(image)

[Rim of air (in cm) to the approx size of pneumothorax (in percentage)]

Treatment of secondary pneumothorax:\

• If the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath, then a chest drain should be inserted.
• Aspiration should be attempted if the rim of air is between 1-2cm. If successful (post aspiration rim size < 1 cm), the patient should be admitted, given high flow oxygen (unless suspected oxygen-sensitive) and observed for at least 24 hours. If aspiration fails (i.e. pneumothorax is still greater than 1cm) a chest drain should be inserted. 
• If the pneumothorax is less the 1cm then the BTS guidelines suggest giving high flow oxygen (unless suspected oxygen-sensitive) and admitting for 24 hours.

Pneumothorax management flow-chart (image)

[Management of spontaneous pneumothorax (from here)]

The BTS guidelines for diving and air travel in the post pneumothorax period:

• Scuba diving: Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.
• Air travel: It is acceptable once the pneumothorax has fully resolved. A patient should only air travel at least 2 weeks after the complete aspiration of the air and confirmed full inflation of the lung.

Additional

Aspiration Vs Chest drain 

The aspiration is done in the second intercostal space anteriorly in the mid-clavicular line using a 16 F cannula. It needs to be discontinued if-

• Resistance is felt
• The patient coughs excessively, or 
• More than 2.5 L of air is removed

Intercostal chest drains are inserted in the fourth, fifth or sixth intercostal space in the mid-axillary line, connected to an underwater seal or one-way Heimlich valve. The drain should be removed the morning after the lung has fully re-inflated and the bubbling has stopped. Continued bubbling after 5–7 days is an indication for surgery. If bubbling in the drainage bottle stops before full re-inflation, the tube is either blocked or kinked or displaced

Source:

• Davidson's Principles and Practice of Medicine; 23rd Edition; page: 625
• Step Up To MRCP Review Note For Part I & Part II By Dr Khaled El Magraby; page: 215