Pneumothorax Management

Ventilation and Air Leak

• Intermittent Positive Pressure Ventilation (IPPV) should be avoided in pneumothorax management due to increased risk of air leak and pneumothorax progression, as recommended by the American Thoracic Society 1
• Positive pressure ventilation can worsen air leaks in pneumothorax, with a reported association with increased risk of pneumothorax, making it one of the leading causes (7%) of iatrogenic pneumothorax 1
• If ventilation is required, use the lowest possible positive pressure settings to minimize the risk of air leak and pneumothorax progression 1

Chest Tube Placement and Management

• Immediate chest tube placement (24F-28F) is recommended for patients with pneumothorax, especially those requiring mechanical ventilation, as suggested by the American College of Chest Physicians 2
• Ensure proper chest tube placement before initiating positive pressure ventilation to prevent worsening pneumothorax or development of tension pneumothorax 1
• Patients with pneumothorax on positive pressure ventilation should be treated with a chest drain unless immediate weaning from positive pressure is possible 1
• Unstable patients should be treated with a 24F to 28F chest tube, while stable patients not at risk for large air leaks can be treated with 16F to 22F chest tubes, as recommended by the American College of Chest Physicians with very good consensus and good consensus, respectively 2
• Small-bore catheter (≤14F) may be acceptable for small pneumothoraces and based on patient preference, with good consensus from the American College of Chest Physicians 2

Airway Clearance and Aerosol Therapies

• Some airway clearance therapies (positive expiratory pressure and intrapulmonary percussive ventilation) should be avoided in pneumothorax, as recommended by the American Thoracic Society 3
• Aerosol therapies can generally be continued in patients with pneumothorax, with no reported increased risk of air leak or pneumothorax progression 3

Tension Pneumothorax Management

• Tension pneumothorax may be missed in ICU settings, especially in ventilated patients who suddenly deteriorate, highlighting the need for close monitoring and prompt recognition 1
• For tension pneumothorax, use a cannula at least 4.5cm long for needle decompression, as recommended by the American College of Surgeons 1
• Administer high-flow oxygen (10 L/min) to the patient, as recommended by the American Thoracic Society 1
• Perform immediate needle decompression by inserting a cannula of at least 4.5 cm length in the second intercostal space in the mid-clavicular line (2MCL) or the fifth intercostal space along the mid-axillary line (5MAL) for right-sided tension pneumothorax, as suggested by the World Journal of Emergency Surgery 4
• Place a definitive chest tube (intercostal drain) immediately after needle decompression, as recommended by the American Thoracic Society 1

Complications and Follow-up

• The following complications are associated with pneumothorax:

• Consider intervention to prevent recurrence after first occurrence of secondary pneumothorax due to potential lethality, as recommended by the American College of Chest Physicians 2
• Patients should avoid air travel until chest radiograph confirms complete resolution, and diving should be permanently avoided after a pneumothorax unless the patient has had bilateral surgical pleurectomy, with follow-up arranged within 7-10 days after discharge to confirm complete resolution and provide advice on smoking cessation to reduce recurrence risk, as recommended by post-discharge care guidelines 1, 5, 6

Chest Tube Removal

• The American Thoracic Society recommends that chest tubes should not be removed in the presence of underlying lung collapse, unless specific criteria are met, including clinical stability and asymptomatic status for at least 14 days, no subcutaneous emphysema, and a stable pleural space deficit 2
• Chest tube removal criteria include a trial period without suction, followed by observation for 5-12 hours to confirm stability, as recommended by 62% of experts 2
• The chest tube should be removed when clinical resolution is achieved, chest radiograph confirms lung re-expansion, and air leak has resolved, as recommended by the American College of Chest Physicians 7
• Proper analgesia must be provided, including infiltration of the skin site with local anesthetic before incision and consideration of opioid administration for additional pain control, as recommended by the American College of Chest Physicians 8
• Adequate analgesia should be provided before chest tube removal, and the tube should be removed during expiration with a brisk, firm movement, as recommended by the American College of Chest Physicians 7