Pneumothorax

Spontaneous Pneumothorax
- Primary pneumothoraces occur in otherwise healthy people without any lung disease
- Secondary pneumothoraces arise in subjects with underlying lung disease.
- Incidence up to 28/100,000 per year  
- Risk of recurrence 54% in first 4 years  
- No need for CXR in expiration
- CT recommended  
         - Differentiate pneumothorax from bullous disease
         - Plain film obscured by subcutaneous emphysema 
- Symptoms associated with secondary pneumothoraces are more severe  
- Many patients with primary pneumnothoraces do not seek help for several days. 
- Plain PA CXR underestimates pneumothorax size.
- Management is no longer dictated by the size of the pneumothorax.
 
Management
- As per Pneumothorax Pathway below. Many can be managed managed conservatively.
- Aspiration is first line treatment for most symptomatic primary pneumothoraces.  
- If a chest drain is indicated use size 8-12F.  
- Ask senior ED doctor to supervise chest tube insertion.  
- All patients with secondary pneumothoraces require hospital admission. 
 
Aspiration
- Special kits are available which use a seldinger technique and have a non kinking catheter. Otherwise use a 14 G venflon, a three way tap and a 50 ml syringe. This can be left in until post CXR in case further aspiration is needed. -  If the 1st aspiration was unsuccessful, then a second attempt at simple aspiration of the pneumothorax should be considered unless >2.5 l was aspirated during the unsuccessful first attempt.
- Repeat CXR after aspiration 
 
Discharge  
- Patients fit for discharge as per Pneumothorax pathway should be reviewed in ED within 48hrs for repeat CXR.
- Primary pneumothoraces that have been successfully aspirated can be discharged after a four hour period of observation
- All patients who are discharged should be reviewed within 48 hours for repeat CXR
 
Discharge instructions
- All patients to be advised to return if worsening breathlessness or pain
- Patients should not fly for one week after CXR resolution of the pneumothorax
- Should avoid exercise and using wind instruments until symptoms fully resolved
- Patients should not scuba dive unless they have a surgical pleurectomy. 
                                                

Roberts ME, et al. Thorax 2023;78:1143–1156. doi:10.1136/thorax-2023-220304 

 

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