Thorax. May;58 Suppl 2:ii BTS guidelines for the management of spontaneous pneumothorax. Henry M(1), Arnold T, Harvey J; Pleural Diseases. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline MacDuff A(1), Arnold A, Harvey J; BTS Pleural Disease . If Bilateral/Haemodynamically unstable proceed to chest drain. BTS Pleural Disease Guideline MANAGEMENT OF SPONTANEOUS PNEUMOTHORAX.
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A pneumothorax is a collection of gas in the pleural space that results in a variable amount of lung collapse on the affected side. By definition, spontaneous pneumothoraces occur in the absence of any trauma including iatrogenic sponyaneous to the chest wall.
Primary spontaneous pneumothoraces occur in people with no underlying lung pathology. Secondary spontaneous pneumothoraces occur in patients with pre-existing lung parenchymal or pleural pathology e.
The classic presentation is that of sudden onset of pleuritic chest pain and dyspnoea at rest. The symptoms do not correlate closely with the size of the pneumothorax In many cases the symptoms are mild and approximately half of patients will present after more than 2 guidelinees of symptoms The symptoms are fpr more severe than those associated with a primary pneumothorax because lung function may already have been compromised by the underlying pathological process.
The symptoms will vary depending on the cause e. Unlike symptoms, the examination findings in primary spontaneous pneumothoraces are affected by the size of the pneumothorax. A small pneumothorax can be impossible to identify on clinical examination.
If the pneumothorax is large then some of the following features may be present:. If the pleural leak exerts a one-way valve effect then a tension pneumothorax can develop. This recognition and management of this complication is discussed later in the session. The most useful investigation is the PA chest radiograph despite the fact that it tends to guideines the size of a pneumothorax by virtue of it being a 2-dimensional image of a 3-dimensional structure. In the British Thoracic Society14, proposed a method for quantifying pneumothorax size on a PA radiograph by measuring the distance from the lung edge to the thoracic wall at the level of the hilum:.
When following the BTS guidelines, pneumothorax size should be determined on a PA chest radiograph by measuring the distance from the lung edge to the thoracic wall at the level of the hilum and not at the apex. The diagnosis is made by the visualising the visceral pleura lung edge separated from the thoracic cage with no visible lung marking between the two. Small pleural effusions are sometimes seen. Spontaneohs main indication for performing additional views would be where a secondary pneumothorax is suspected as identification of even a small pneumothorax in this setting may significantly influence management.
However, the increased access to CT which is the most sensitive investigation has led to a significant reduction in the numbers of requests for additional lateral views. Expiratory films add little to the PA radiograph and are not routinely recommended. The presence of lung markings beyond the line in question, repeating the films with possible artefacts removed or comparison to previous films usually clarifies the situation.
CT is considered the gold standard at identification of a pneumothorax and is particularly valuable when radiographs are difficult to interpret or specific drain placement is required eg bullous lung disease, loculated pneumothoraces, surgical emphysema. However, it is highly user dependent and for patients with suspected spontaneous pneumothoraces, radiography has the advantage of identifying unexpected causes of pleuritic pain eg infection, carcinoma.
Having said this, with the increasing use of spoontaneous in Emergency Medicine, in the hands of an experienced user it can now reliably detect pneumothorax better than an anteroposterior chest radiograph. Arterial gas off may demonstrate hypoxia21 but the information gained is unlikely to alter the management plan. Their main use is when administering supplemental oxygen to patients with pneumothoraces secondary to COPD. Management depends upon whether the patient is symptomatic, whether the pneumo-thorax is primary or secondary, and its size on the PA radiograph.
The guidance below is based upon the BTS guidelines Different guidelines have been adopted by other international bodies A pneumothorax will resolve up to 4 times faster if high flow oxygen is administered.
Ov to breathing room air, a pneumothorax will resolve 4 times faster if the patient is on high flow oxygen For patients with COPD, fixed concentration oxygen should be administered.
Entonox diffuses into air spaces and can convert an uncomplicated pneumothorax into a tension pneumothorax. Its use as an analgesic is contraindicated in this setting. Patients with spontaneous secondary pneumothoraces less than 1cm in size and minimal symptoms do not require drainage in the ED but should be admitted for observation and supplemental oxygenation.
Symptomatic patients and those with large pneumothoraces, whether primary or secondary, require intervention. There are two diagrams depicting the recommended treatment algorithm for a primary and secondary spontaneous pneumothorax, these are available to download at the end of this pneumothorac.
Needle aspiration is technique that describes aspiration of air via the chest wall without insertion of a chest drain thoracostomy tube. Successful aspiration is associated with a much higher likelihood of discharge than ot drain insertion and fewer complications have been reported Following successful aspiration, patients with primary pneumothoraces should have a short period of observation in the Emergency Department before discharge.
Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline
Recurrence rates are similar at 7 days and 1 year compared to thoracostomy tube insertion The BTS guidelines recommend use of a cannula no greater than 16G in diameter for aspiration though evidence that larger cannulae guidellnes more likely to cause a persistent pleural leakis limited. It should be remembered that narrower cannulae are also shorter and may not be long enough to reach the thoracic cavity in larger patients.
Needle aspiration is less likely to succeed for secondary pneumothoraces 15 and is only recommended in this setting if the patient has a small pneumothorax cm in size and minimal symptoms.
Following successful aspiration, patients with secondary pneumothoraces should be admitted for observation. Table 5 describes a method of needle aspiration. Identification of the the 2nd intercostal space is achieved by locating the end of the 2nd rib mediall where it attaches at the manubriosternal angle. The ribspace below the rhe rib is the 2nd intercostal space.
BTS guidelines for the management of spontaneous pneumothorax.
Traditionally, the treatment for a large pneumothorax has been the insertion of a large eg 28FG drain through an incision in the chest wall. In the last decade there has been a move toward inserting smaller drains percutaneously.
Small drains eg FG have been shown to be associated with fewer complications particularly subcutaneous emphysema without prolonging time pneumothlrax resolution Small drains may be associated with a higher failure rate when draining very large pneumothoraces but currently this evidence is limited.
In obese patients the Seldinger technique may not be technically possible as the needle may be too short to traverse the chest wall. Whichever technique is used the landmarks are the same. Insertion in the safe triangle picture attempts to avoid injury to the long thoracic nerve and lateral thoracic gukdelines, which sit in the mid-axillary line.
This triangle is formed by the anterior border of latissimus dorsi posteriorly, the lateral aspect of pectoralis major anteriorly, and the 6th rib spontaeous forming an apex below the axilla. In young, thin males the nipple will lie in the 5th intercostal space. Insertion of the drain just above the underlying rib minimises the risk of managemnet to the intercostal bundle.
Both techniques are low risk in experienced hands. However, the National Patient Safety Agency30 has issued specific recommendations s;ontaneous reports of 12 deaths and 15 cases of serious harm associated with drain insertion between and Chest drain insertion is potentially dangerous, 27 cases of death or serious harm were reported as a result of chest drain insertion in the UK between and This is probably a conservative figure.
This procedure should only be performed by a person trained and signed off as competent to do so. A method of inserting a drain using a Seldinger technique is described in table 5 and the contents of one commercial kit are shown below. Holding the dilators close to the chest wall should prevent excessive force of insertion or a sudden give. These are solid objects and on the left side the apex of the heart lies close to the insertion point!
The BTS recommends that any patient rhe admission be reviewed by a respiratory physician within 24 hours. Chest drain suction high volume, low pressure should be considered when lung re-expansion has not occurred 48 hours after chest drain insertion, which is suggestive of an ongoing air leak.
Earlier application of suction is not recommended because of concerns over precipitating re-expansion pulmonary oedema, which conveys a significant mortality risk The lung capillaries become leaky following a pneumothorax and mangaement of additional mechanical stresses can result in oedema. There is often no ongoing air leak in spontaneous pneumothoraces and lower mechanical stresses will be caused by aspiration or thoracostomy tube insertion without suction.
Re-expansion pulmonary oedema is more common in patients under 30 years old, those with late presentation of a pneumothorax and those with large pneumothoraces The risk of pneumothorax recurrence increases in pregnancy and conveys a significant risk to both the mother and foetus. Most air mannagement will resolve after 2 weeks but the risk ,anagement infection of prolonged drainage may outweigh the low morbidity rate associated with surgical intervention, which has the added benefit of significantly reducing the future recurrence rate.
This technique is becoming increasingly popular as it is associated with a shorter hospital stay and less postoperative pain. Chemical Pleurodesis is an option for patients that refuse surgery or are considered poor surgical candidates.
Tetracycline or talc can be administered via the chest drain. Patients discharged from the Emergency Department managemet a spontaneous pneumothorax should ideally be reviewed by a respiratory physician after 2 weeks. In practice, it may be impossible to access specialist manageent in the recommended timeframe. If this is manavement case, then the spontanfous should be advised to initially return to the Emergency Department for a repeat chest radiograph and senior doctor review at 2 weeks, pending specialist review.
Most patients with spontaneous pneumothoraces that have resolved need no further follow up. If the pneumothorax is recurrent or the patient has a high risk vocation, referral for a cardiothoracic outpatient appointment is appropriate.
All patients discharged following a pneumothorax should be given verbal and written advice to immediately return to the Emergency Department if pneumothlrax develop breathlessness. Smokers they should be advised to quit and seek assistance from the GP to successfully achieve this.
Changes in atmospheric pressure can rapidly convert simple pneumothoraces to tension pneumothoraces with catastrophic consequences. The BTS Air Travel Working Party38 recommends that patients should be advised to avoid flying for at least a week after a chest radiograph has confirmed complete resolution of their spontaneous pneumothorax, or until they have recovered from a definitive surgical procedure aimed to prevent pneumothorax recurrence. The previous advice to avoid flying for 6 weeks is not supported by existing evidence.
It is advised that 2 weeks have elapsed following confirmed resolution if the pneumothorax was traumatic in origin, which corresponds to the advice issued by the UK civil aviation authority. The British Thoracic Society Fitness to Dive Group39 recommends that underwater diving should be permanently avoided after a pneumothorax, unless the patient has had bilateral open surgical pleurectomy.