Pneumothorax (spontaneous)

Background

Guidelines reproduced with permission from Thorax 2003;58(Suppl ii):ii39-ii52

Primary pneumothaces occur in otherwise healthy people without any lung disease
Secondary pneumothoraces arise in subjects with underlying lung disease
These guidelines are not for trauma related pneumothoraces
Incidence up to 28/100,000 per year
Much higher incidence (12% v 0.1% lifetime risk) in smokers (subpleural blebs / bullae likely role in pathogenesis)
Not related to physical activity
Taller individuals (? larger intrapleural pressure gradient)
Risk of recurrence 54% in first 4 years
No need for expiration CXR
Lateral or lateral decubitus film if clinical suspicion high but PA film is normal
CT recommended:
- Differentiate pneumothorax from bullous disease
- Aberrant tube placement suspected
- Plain film obscured by surgical emphysema
Symptoms associated with 2° pneumothoraces more severe
Many patients with 1° pneumothoraces do not seek help for several days (important in Re-Expansion Pulmonary Oedema
Plain PA CXR underestimates pneumothorax size
Large or small pneumothorax defined by distance between lung margin and chest wall greater or less than 2 cm
2cm gap = 50% pneumothorax by volume

Mx of pneumothorax

Primary pneumothorax occurs in patients who have no clinically apparent lung disorder.

Secondary pneumothorax occurs in patients with an underlying pulmonary disease, most commonly chronic obstructive pulmonary disease (COPD).

Small Pneumothorax: presence of a visible rim of <2 cm between the lung margin and the chest wall.

Large Pneumothorax presence of a visible rim of >2 cm between the lung margin and the chest wall.

General Audit Standards:

90% of patients should be followed according to local policy (but within 2 weeks)
90% of patients should be given written advice on discharge
100% patients should be referred to a respiratory physician if they fail to respond to treatment within 48 hours as an inpatient

Primary Spontaneous pneumothorax - minimal symptoms:

Small pneumothorax - Aspiration should not be performed
Large pneumothorax
- All should be aspirate
- All should have a repeat CXR before discharge

Primary Spontaneous pneumothorax - symptomatic:

All should have chest aspiration
All should have an intercostal drain if aspiration fails
90% of patients should have intercostal drain of < 14 Gauge
Monitor for REPO

Secondary pneumothorax - minimal symptoms

All should be hospitalised
All patients treated successfully with simple aspiration should be admitted to hospital and observed for at least 24 hours
90% of patients with secondary pneumothorax > or = 2cm depth should have an intercostal drain

Secondary pneumothorax - symptomatic

All should be hospitalised
All should have an intercostal drain before leaving the ED
Monitor for REPO

Primary PTX

NO underlying lung disease

If suitable and 1st aspiration unsuccessful, then a second attempt at simple aspiration of the pneumothorax may be considered unless >2.5 l was aspirated during the unsuccessful first attempt
Observation is treatment of choice for small (<2cm) closed pneumothoraces without significant breathlessness
Patients with small (<2cm) primary pneumothoraces without breathlessness should be considered for discharge with early out patient follow up. These patient should be given clear written advice to return if worsening breathlessness
If a patient with a pneumothorax is admitted overnight, they should receive high flow , high flow (10 l/min) oxygen should be administered, with appropriate caution in patients with COPD who may be sensitive to higher concentrations of oxygen
Breathless patients should not be left without intervention regardless of the size of the pneumothorax on a chest radiograph

Secondary pneumothorax

With underlying lung disease

Strong emphasis should be placed on the relationship between the recurrence of pneumothorax and smoking in an effort to encourage patients to stop smoking.

Pneumothorax (Spontaneous)