Consensus Statements
Consensus Panel on the Management
of Spontaneous Pneumothorax
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Consensus Panel Recommendations
Primary Spontaneous Pneumothorax
Clinically Stable Patients With a Small Pneumothorax
Observe in emergency department for 3 to 6 hours and discharge home if repeat chest radiograph excludes progression of pneumothorax (Good Consensus). [Note: Patients may be admitted for observation if they live distant from emergency services or follow-up care is considered unreliable (Good Consensus).]
Follow-up in 12 to 48 hours (Good Consensus). Repeat radiography to document resolution of pneumothorax (Very Good Consensus).
Simple aspiration of the pneumothorax or chest tube insertion is not appropriate for most patients unless the pneumothorax enlarges (Good Consensus).
Clinically Stable Patients With a Large Pneumothorax
Re-expand the lung and hospitalize in most instances (Very Good Consensus).
For lung re-expansion use small-bore catheter (<14F) or place a 16F to 22F chest tube (Good Consensus).
Attach catheter or tube to a Heimlich valve or water seal device (Good Consensus) and leave in place until the lung expands against the chest wall and air leaks resolve. If the lung fails to expand quickly, apply suction to a water seal device. Alternatively, suction may be applied immediately after chest tube placement for all patients managed with a water seal system (Some Consensus).
Reliable patients unwilling to be hospitalized may be discharged with a small-bore catheter attached to a Heimlich valve if the lung re-expanded after removal of pleural air (Good Consensus). Follow-up within 48 hours.
Clinically Unstable Patients With a Large Pneumothorax
Hospitalize and insert a chest catheter to re-expand the lung (Very Good Consensus).
For most patients, use a 16F to 22F standard chest tube or small bore catheter (<14F) (Good Consensus), depending on the degree of clinical instability.
A 24F to 28F standard chest tube may be used if the patient requires positive pressure ventilation or is anticipated to have a large air leak (Good Consensus).
A water seal device can be used without suction initially (Good Consensus), but suction should be applied if the lung fails to re-expand with water seal drainage.
A small-bore catheter attached to a Heimlich valve may be used if clinical stability can be obtained with immediate evacuation of the pleural space (Good Consensus). Substitute the Heimlich valve with a water seal device and apply suction if the lung fails to re-expand (Good Consensus).
Chest Tube Removal
Remove chest tube in a staged manner, to assure that the air leak into the pleural space has resolved (Good Consensus). The first stage requires a radiograph demonstrating complete resolution of the pneumothorax and no clinical evidence of an ongoing air leak. Discontinue any chest tube suction (Good Consensus).
The panel had divided opinion on the question "Should the chest tube be clamped to detect an air leak after re-expansion of the lung?"
- No (53%)
- Yes (47%), 4 hours after the last evidence of an air leak
The panel had divided opinion on the question: "When should chest radiography be repeated after the last evidence of an air leak to ensure that the pneumothorax has not recurred before the chest tube is removed?"
- 5 to 12 hours after the last evidence of an air leak (62%)
- <4 hours (10%), 13 to 23 hours (10%), 24 hours (17%)
Persistent Air Leak
Continue observation for 4 days to assess for spontaneous closure of bronchopleural fistula. If an air leak persists longer than 4 days, evaluate the patient for surgery to close the air leak and perform a pleurodesis procedure to prevent pneumothorax recurrence (Very Good Consensus). Thoracoscopy is the preferred management procedure (Very Good Consensus).
Use of an additional chest tube or bronchoscopy in an attempt to seal endobronchial sites of air leakage is not indicated (Very Good Consensus).
Except in special circumstances where surgery is contraindicated or a patient refuses surgery, chemical pleurodesis should not be used in the management of most patients (Very Good Consensus). If chemical pleurodesis is performed, doxycycline or talc slurry are the preferred sclerosing agents (Good Consensus).
Prevention of Pneumothorax Recurrence
The panel had divided opinion on the question: "Should patients with their first primary spontaneous pneumothorax be offered an intervention to prevent recurrence?"
- Yes (15%)
- No (85%), except for patients with persistent air leaks, an intervention to prevent recurrence should be reserved for the second pneumothorax.
The occupational and recreational interests of patients (eg, flying, scuba diving) should be considered in timing an intervention. Thoracoscopy is the preferred procedure for preventing pneumothorax recurrence (Very Good Consensus). Chemical pleurodesis through a chest tube is an acceptable alternative to thoracoscopy in certain patients (Good Consensus), although thoracoscopy has a higher success rate.
Thoracoscopy can be performed with or without video assistance. Intraoperative bullectomy should be performed (Very Good Consensus) by staple bullectomy (Very Good Consensus) in patients with apical bullae visualized at surgery.
Intraoperative pleurodesis should be performed in most patients, with parietal pleural abrasion limited to the upper half of the hemithorax (Good Consensus).
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