if tension pneumothorax is present, a cannula of adequate length should be promptly inserted into the second intercostal space in the mid clavicular line and left in place until a functioning intercostal tube can be positioned.
the size of a pneumothorax is divided into “small” or “large” depending on the presence of a visible rim of <2 cm or >2 cm between the lung margin and the chest wall.
patients with small (<2 cm) primary pneumothoraces not associated with breathlessness should be considered for discharge with early outpatient review. These patients should receive clear written advice to return in the event of worsening breathlessness.
if a patient with a pneumothorax is admitted overnight for observation, 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.
simple aspiration is recommended as first line treatment for all primary pneumothoraces requiring intervention.
primary pneumothorax patients treated successfully by simple aspiration should be observed to ensure clinical stability before discharge.
repeated aspiration is reasonable for primary pneumothorax when the first aspiration has been unsuccessful (i.e. patient still symptomatic) and a volume of <2.5 l has been aspirated on the first attempt.
catheter aspiration of pneumothorax (CASP) can be used where the equipment and experience is available.
catheter aspiration kits with an integral one way valve system may reduce the need for repeat aspiration.
if simple aspiration or catheter aspiration drainage of any pneumothorax is unsuccessful in controlling symptoms, then an intercostal tube should be inserted.
intercostal tube drainage is recommended in secondary pneumothorax except in patients who are not breathless and have a very small (<1 cm or apical) pneumothorax.
there is no evidence that large tubes (20–24 F) are any better than small tubes (10–14 F) in the management of pneumothoraces. The initial use of large (20–24 F) intercostal tubes is not recommended, although it may become necessary to replace a small chest tube with a larger one if there is a persistent air leak.
suction to an intercostal tube should not be applied directly after tube insertion, but can be added after 48 hours for persistent air leak or failure of a pneumothorax to re-expand.
a bubbling chest tube should never be clamped.
a chest tube which is not bubbling should not usually be clamped.
if a chest tube for pneumothorax is clamped, this should be under the supervision of a respiratory physician or thoracic surgeon, the patient should be managed in a specialist ward with experienced nursing staff, and the patient should not leave the ward environment.
if a patient with a clamped drain becomes breathless or develops subcutaneous emphysema, the drain must be immediately unclamped and medical advice sought.
diving should be permanently avoided after a pneumothorax, unless the patient has had bilateral surgical pleurectomy.