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