New treatment guidelines

• New guidelines have moved away from management guided by pneumothorax size. Management is now guided by symptoms and the degree of physiological compromise

  Emergency management of a tension pneumothorax has not changed (emergency needle decompression and chest drain insertion)
• If the patient is not symptomatic:

  • Usually conservative management
  • Regular review as outpatient if primary pneumothorax
  • Review as an inpatient if secondary pneumothorax
• If the patient is symptomatic:

  • If high risk characteristics and pneumothorax sufficient size = chest drain
  • If no high risk characteristics = needle aspiration, chest drain if not resolved
• High risk characteristics:

  • Haemodynamic compromise
  • Significant hypoxia
  • Bilateral pneumothorax
  • Underlying lung disease
  • 50 or older with significant smoking history
  • Haemopneumothorax
• If a chest drain is inserted, look out for:

  • Swinging: the fluid in the chest drain tubing moves towards the patient during inspiration (due to reduced intrathoracic pressure during inspiration when the diaphragm descends).
  • Bubbling: the fluid in the chest drain bottle bubbles when the pneumothorax is initially drained (this should stop eventually). The persistence of bubbling for >48 hours may indicate an air leak, which is a connection between the bronchial tree and pleural space (also known as a bronchopleural fistula). This may need to be discussed with a thoracic surgeon.
• Follow up:

  • Should have OP respiratory follow up and a repeat chest x-ray in 2-4 weeks so assess for resolution. Advise not to fly until full resolution
  • A recurrent/difficult pneumothorax may need an open thoracotomy and pleurectomy - parietal pleural removed, so the lung sticks to the inner surface of the chest wall
  • Medical pleurodesis may be needed in patients unfit for surgery - chemical (tetracycline or talc) obliterates the space between the visceral and parietal pleura