Depending on the extent of the pneumothorax, the following measures may be used:
- Close observation – for small pneumothorax (pleural gap <1 transverse finger) in lung healthy patients.
- Needle/catheter aspiration – in the stable patient, after aspiration of the air and after X-ray control, it may be possible to dispense with the placement of a chest drain; in the emergency situation for immediate temporary relief of a tension pneumothorax (→ large-lumen indwelling venous cannula in the 2nd ICR (intercostal space/space between two adjacent ribs) punctured medioclavicularly (middle of the clavicle)).
- Creation of a chest drain – standard in symptomatic pneumothoraxProcedure: Local anesthesia (local anesthesia); place the drain in the 5th or 6th intercostal space (ICR) at the level of the tip of the scapula (“tip of the scapula”) in the anterior axillary line; incision for this purpose is a maximum of 2 cm; after placement of the drain, it is fixed by means of a suture back with a loop. Note: Work along the upper edge of the rib, where there are few vessels and nerves. Do not use a trocar because of the risk of lung injury when jerkily piercing the pleura (lung pleura).After placement, the chest drainage is provided with a surgeon’s cap; if necessary, a suction is created (pleural drainage; in this case, pleural suction drainage).Progress is monitored by daily chest X-ray. After complete lung deployment, the drainage is clamped for one to two days; if the lung remains deployed during this time, the drainage can be removed. Removed drainage is usually after the third to fifth dayPossible complications: Occurrence of re-expansion edema (water retention/edema) after the lung has re-expanded. This can increase to respiratory depression and death of the patient (incidence about 6%).
- Chemical pleurodesis (procedure in which the pleura visceralis is joined to the pleura parietalis) – may be indicated for recurrent (reoccurring) primary spontaneous pneumothorax; common agents are tetracycline and talc
- Surgical therapy (see below); in one quarter of hospitalized patients.
- In the presence of an open pneumothorax, the wound must be immediately covered sterilely; however, it must not be completely taped with the bandage, because then there is again the risk of tension pneumothorax
In the case of an undrained pneumothorax, resorption may take several weeks (circa 50 ml/d).
Further notes
- In younger patients with spontaneous pneumothorax with no apparent cause, chest drainage did not show clear benefits: recovery was not discernibly accelerated compared with a wait-and-see approach.
Operative order 1st order
Thoracoscopy (reflection of the chest) with resection of bullae (bladders)/partial pleurectomy (removal of the pleura) is indicated for:
- Condition after 2 times spontaneous pneumothorax on the same side.
- Bilateral pneumothorax tension pneumothorax (also first event).
- Incomplete expansion of the lung despite chest drainage.
- Pneumothorax in severely reduced general condition (AZ).
- Evidence of bullae on CT
- Persistent parenchymal fistula (> 7 days).
- Hematopneumothorax (simultaneous accumulation of blood and air in the pleural space).
- Empyema (accumulation of pus)
- Occupational hazard (aircrew, divers)
- Patient request, risk factors
