A Practical Approach to Pneumothorax Management

Abstract

Pneumothorax, defined by the presence of air in the pleural cavity, is a potentially life-threatening condition requiring prompt diagnosis and tailored management. Rapid and accurate diagnosis is primarily achieved through radiological imaging. Management strategies for pneumothorax vary according to severity and aetiology. Conservative care, involving vigilant observation and supplemental oxygen, is suitable for small, stable pneumothoraxes. Needle aspiration can be an effective first-line treatment, although it may fail in some instances, necessitating escalation. Ambulatory devices facilitate outpatient care and reduce the length of hospital stays. Chest drainage remains a cornerstone therapy. Indwelling pleural catheters may be implemented in selective cases. Endobronchial treatments, including valves and spigots, offer minimally invasive options for reducing the flow of air leaks. Medical thoracoscopy with talc poudrage provides both diagnostic and therapeutic benefits in patients unsuitable for surgery, while surgical intervention represents the gold standard for definitive treatment. Adjunctive interventions include talc slurry pleurodesis and autologous blood patch pleurodesis for patients unsuitable for surgery. Effective management necessitates individualized treatment plans, incorporating risk factor modification, pain management, and physiotherapy. This practical approach aims to update the reader on the treatment modalities that can be used in all forms of pneumothorax in clinical practice.

Keywords: Blood patch; Drainage; Physical therapy; Pneumothorax; Talc; Thoracoscopy.

Fig. 1

Procedural flow chart related to pleural aspiration with needle or cannula. CT computed tomography

Fig. 2

Management of SSP by thoracic drainage followed by pleural aspiration. a Radiological demonstration of a right pneumothorax on chest X-ray. b Chest tube placement with partial lung expansion. c Thoracic tomographic evidence of occluded and trapped drainage in scissural location. d Evidence of persistent anterior pneumothorax (patient in supine decubitus) with size over 2 cm in a symptomatic patient requiring high oxygen flows. e Treatment outcome after thoracic drain removal and manual suctioning of the anterior residual pneumothorax with a catheter; evidence of complete lung expansion. SSP secondary spontaneous pneumothorax

Fig. 3

Devices for the ambulatory management of pneumothorax with or without associated pleural fluid. a Traditional Heimlich valve with collection bag in a patient with malignant pleural effusion and a large broncho-pleural fistula both treated with an IPC. b Solid collection chamber with an associated one-way valve (Redax® Drentech WearABLE™) attached to an IPC. c All-in-one device with built-in one-way valve (Rocket® Pleural Vent™). IPC indwelling pleural catheter

Fig. 4

Procedural flow chart related to talc slurry pleurodesis. CT computed tomography

Fig. 5

a, b Inflammatory pleural plaques (histologically confirmed) as an outcome of previous talc slurry in a patient undergoing medical thoracoscopy for SSP recurrence. SSP secondary spontaneous pneumothorax

Fig. 6

Procedural flow chart related to autologous blood patch pleurodesis. CT computed tomography

Fig. 7

Stages in the management with medical thoracoscopy of an SSP patient with multiple comorbidities and contraindication to surgery. a Axial thoracic tomography image showing a right pneumothorax with subcutaneous emphysema and pleural drainage in place. b Coronal chest CT image showing the position of the large-calibre drainage. c Endoscopic view while performing medical thoracoscopy with talc poudrage demonstrating the presence of long-standing adhesions. d Post-thoracoscopic chest X-ray demonstrating partial lung re-expansion. e, f Axial and coronal post-thoracoscopy chest CT images showing partial pleural apposition, sufficient for the removal of the pleural drainage with a patient in symptomatic control. The patient is then discharged and reassessed with distant radiographic follow-up. CT computed tomography