Emergency Management of Pneumothorax

Initial Assessment

Evaluate clinical stability by assessing respiratory rate, heart rate, blood pressure, oxygen saturation, and ability to speak in complete sentences between breaths, according to the American College of Chest Physicians 1, 2
Determine pneumothorax size as small (<3 cm apex-to-cupola distance) or large (≥3 cm apex-to-cupola distance) on upright chest radiograph, as recommended by the American College of Chest Physicians 1, 2

For clinically stable patients with small pneumothorax, observe in the emergency department for 3-6 hours and obtain repeat chest radiograph to exclude progression, as suggested by the American College of Chest Physicians 2
For clinically stable patients with large pneumothorax, perform a procedure to reexpand the lung, such as using a small-bore catheter (≤14F) or moderate-sized chest tube (16F to 22F), and hospitalize in most instances, according to the American College of Chest Physicians 1, 2
For clinically unstable patients with large pneumothorax, hospitalize with immediate insertion of a chest catheter, using either a moderate-sized chest tube (16F to 22F) or small-bore catheter, as recommended by the American College of Chest Physicians 1, 2
For tension pneumothorax, perform immediate needle decompression in the second intercostal space in the mid-clavicular line using a cannula (French gauge 16 or larger and at least 3 cm long), as recommended by the American Heart Association 5, 6

Patients with underlying lung disease typically present with more severe symptoms and may require more aggressive management, according to the American College of Chest Physicians 3
In patients with asthma, tension pneumothorax is a rare but potentially reversible cause of arrest that requires immediate recognition and treatment, as stated by the American Heart Association 6

Explain the procedure to the patient and provide reassurance, and consider premedication with atropine to prevent vasovagal reaction, as recommended by the British Medical Journal 5

Monitor vital signs and respiratory status, and keep chest tube or catheter in place until the lung expands against the chest wall and air leaks have resolved, as suggested by the American College of Chest Physicians 1, 5