SIGNS AND SYMPTOMS 
History
- Severity of symptoms is generally proportional to size of the pneumothorax.
- Chest pain on the ipsilateral side:
- Sharp, pleuritic pain
- Sudden onset
- Dull ache in delayed presentations
- Shortness of breath
- Rarely cough, asymptomatic, or generalized malaise
Physical Exam
- Tachypnea
- Heart rate < 120 bpm generally seen in simple spontaneous pneumothoraces
- Jugular venous distention and tracheal deviation to the contralateral side may be evident in tension pneumothorax.
- Cardiac and pulmonary exam:
- Asymmetric decreased breath sounds
- Hyperresonance to percussion of ipsilateral side
- Tension pneumothorax:
ESSENTIAL WORKUP
- Imaging is mainstay of the workup
- DO NOT delay chest decompression if the patient is hemodynamically unstable and there is sufficient clinical evidence of pneumothorax.
DIAGNOSIS TESTS & INTERPRETATION
Lab
Arterial blood gas offers little over oxygen saturation.
Imaging
- Chest radiograph:
- Patients unable to tolerate upright chest radiograph can be taken in decubitus position with the suspected side up:
- Absence of lung markings distal or peripheral to the visceral pleural white line
- Displacement of mediastinum or anterior junction line
- Deep sulcus sign
- On frontal view, larger lateral costodiaphragmatic recess than on opposite side
- Diaphragm may be inverted on the side with deep sulcus:
- A rough estimate of pneumothorax size is sufficient to make clinical decisions.
- Expiratory film:
- May demonstrate small pneumothorax but has not been shown to increase yield of detection
- Chest CT:
- Very sensitive for small pneumothorax but has little practical advantage over chest radiograph
- US:
- User experience required
- Rapid at bedside
- Lack of lung sliding and comet-tail artifact signifies pneumothorax.
- M-mode confirms pneumothorax with smooth lines above and below pleural line.
- With experience, sensitivity surpasses chest radiograph
Diagnostic Procedures/Surgery
ECG:
- Often necessary to rule out cardiac etiologies of chest pain
- Nonspecific changes include T-wave inversion, left axis deviation, and decreased R-wave amplitude.
DIFFERENTIAL DIAGNOSIS
[Outline]
PRE-HOSPITAL
ALERT
Unstable patients with a suspected tension pneumothorax require immediate needle thoracostomy.
INITIAL STABILIZATION/THERAPY
- Cardiac monitor
- Pulse oximetry
- Oxygen 100% via nonrebreather face mask
- IV access
- Suspected tension pneumothorax requires either immediate needle thoracostomy or tube thoracostomy.
- Needle thoracostomy:
- Immediate placement indicated in unstable patients with a tension pneumothorax
- 14G–18G angiocatheter in the 2nd intercostal space at midclavicular line or 4th or 5th intercostal space at anterior axillary line
- NOTE: The length of most standard angiocatheters is too short to penetrate the pleural cavity in moderate to large framed patients – longer, purpose-specific catheters may be required
ED TREATMENT/PROCEDURES
- Nontraumatic pneumothorax estimated at < 15% collapse and no cardiovascular or respiratory compromise:
- Observe with 100% oxygen support for 4–6 hr.
- Repeat chest radiograph and discharge if unchanged.
- Simple aspiration:
- Indications:
- Simple pneumothorax with only 15–30% collapse
- Increase in size of a small pneumothorax during observation
- Placement of aspiration catheter (typically 8F) with 3-way stopcock
- Aspirate air until resistance or 3 L of air aspirated.
- If the pneumothorax is no longer visible on 2 subsequent chest radiographs at 4 hr intervals, remove catheter.
- If a final chest radiograph is normal 2 hr after the catheter is removed, the patient may be discharged.
- A 2nd aspiration may be attempted if the pneumothorax does not resolve.
- Heimlich valve:
- Indicated when < 30% collapse after failure of aspiration
- Attach Heimlich valve to aspiration catheter or chest tube.
- Suction:
- Indicated when the Heimlich valve fails
- Attach aspiration catheter to suction at 20 cm H2O.
- Observe in ED for 1 hr.
- Tube thoracostomy:
- Indications:
- Suspicion of a tension pneumothorax
- Gunshot wound to the chest
- Clinical evidence of a pneumothorax following blunt chest trauma or penetrating chest trauma
- Presence of a pneumothorax of any size in patient receiving positive-pressure ventilation
- Pneumothorax with > 30% collapse
- Most cases of secondary pneumothorax
- Definitive therapy after needle thoracostomy
- Tube size:
- Small-caliber (7–14F) tube for primary spontaneous pneumothoraces
- 20–28F for secondary spontaneous pneumothorax
- 28F when there is detectable pleural fluid or an anticipated need for mechanical ventilation
- Check for tube kinks by fully rotating the inserted tube.
- All side holes in the tube must be within the chest wall to avoid leak.
- Following insertion, the tube should be connected to a water-seal device.
- A Heimlich valve may be used instead of a water-seal device in stable patients without a pleural effusion.
- Re-expansion edema is a rare complication requiring supportive care.
- Possible complications:
- Intercostal vessel bleeding
- Inadequate drainage:
- Kinked tube
- Clogged tube
- Communication outside of pleural cavity with leak
- Re-expansion pulmonary edema:
- Treatment with fluid resuscitation
MEDICATION
- Local anesthetic:
- 1% lidocaine with epinephrine 1:100,000
- Max. dose: 7 mg/kg–500 mg
- Consider procedural sedation in stable awake patients
- No indication for antibiotics in a clean procedure
[Outline]
DISPOSITION
Admission Criteria
- Tension pneumothorax
- Chest tube required
Discharge Criteria
- < 15% collapse, no expansion while in the ED or successful aspiration with catheter removed:
- Discharge with follow-up in 24 hr and 1 wk for chest radiograph to assure re-expansion.
- Reliable patients with the thoracic vent and successful aspiration or secured catheter and Heimlich valve:
- Discharge with 24 and 48 hr follow-up.
- At 48 hr follow-up:
- Clamp catheter, observe for 2 hr, and repeat chest radiograph.
- Remove thoracic vent or catheter if no re-expansion.
- Observe for 2 hr and repeat chest radiograph.
- If no re-expansion, discharge with 24 hr and 1 wk follow-up.
- Discharge instruction should include prompt return for new onset of chest pain or dyspnea.
- Patients without re-expansion at 1 wk require a cardiothoracic surgery consult.
FOLLOW-UP RECOMMENDATIONS
Pulmonary medicine and/or chest surgery
[Outline]
- Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: An American College of Chest Physicians Delphi consensus statement. Chest. 2001;119:590–602.
- Gaudio M, Hafner JW. Simple aspiration compared to chest tube insertion in the management of primary spontaneous pneumothorax. Ann Emerg Med. 2009;54:458–460.
- Hassani B, Foote J, Borgundvaag B. Outpatient management of primary spontaneous pneumothorax in the emergency department of a community hospital using a small-bore catheter and a Heimlich valve. Acad Emerg Med. 2009;16:513–518.
- Soldati G, Testa A, Sher S, et al. Occult traumatic pneumothorax: Diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008;133:204–211.
- MacDuff A, Arnold A, Harvey J, et al. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii18–ii31.
- Zehtabchi S, Rios Cl. Management of emergency department patients with primary spontaneous pneumothorax: Needle aspiration or tube thoracostomy? Ann Emerg Med. 2008;51:91–100.
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