Initial Management of Pneumothorax Using British Thoracic Society (BTS) Guidelines

 

NOTE: This does not apply to a patient with a tension or traumatic pneumothorax.

 

Questions:

(1) Does the patient have a chronic lung disease (COPD, cystic fibrosis, etc.)?

(2) How much has the lung collapsed?

(3) Does the patient have significant dyspnea?

Upright Chest Radiograph	Degree of Collapse
small rim of air	small
lung collapsed half-way to heart border	moderate
airless lung, separate from the diaphragm	complete

 

Management Decisions

 

Step 1: Start oxygen and an intravenous line.

Step 2: Determine initial management.

 

Chronic Lung Disease	Lung Collapse	Level of Dyspnea	Management
yes	moderate to complete	NA	aspiration
yes	small	significant	aspiration
yes	small	not significant	in patient observation
no	complete	NA	aspiration
no	small to moderate	significant	aspiration
no	small to moderate	not significant	outpatient observation

 

Aspiration technique:

(1) Inject a local anesthetic into the and subcutaneous tissue in the midclavicular line just above the third rib.

(2) Insert a 16 gauge intravenous cannula into the second intercostal space (just above the third rib in the midclavicular line).

(3) Remove the needle from the cannula and attach a 3-way valve.

(4) With a large syringe aspirate air, using the 3 way valve to prevent air entry into the lungs.

(5) The endpoint is either (a) patient coughs excessively, or (b) 2.5 liters of air is withdrawn through the syringe.

(6) Take an upright chest X-ray to determine if the lung has expanded.

 

If aspiration successful, then observe patient (as an inpatient if chronic lung disease present, else as outpatient.

 

If aspiration unsuccessful, then perform intercostal tube drainage.

 

NOTE: This would apply to a unilateral pneumothorax. I am not sure if it would also apply to management of a patient with a bilateral pneumothorax.