What are the options for restoring air-free plural space in asymptomatic pneumothorax?

Updated: Apr 28, 2020
  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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Answer

Simple observation is appropriate for asymptomatic patients with a minimal pneumothorax (<15-20% by Light criteria; 2-3 cm from apex to cupola by alternate criteria) with close follow-up, ensuring no enlargement (see Estimating the size of the pneumothorax under Chest Radiography). Air is reabsorbed spontaneously by 1.25% of pneumothorax size per day. [56]

A multicenter, prospective, observational study reported on more than 500 trauma patients with occult pneumothorax identified on CT with an initially normal chest radiograph. Controversy exists in the literature on the treatment of all patients with occult pneumothorax, whether to closely observe patients with occult pneumothorax or whether to place a chest tube. It is even more controversial in patients on positive pressure ventilation. It is generally accepted after trauma to treat pneumothorax seen on chest radiographs with chest tube thoracostomy. Conversion to tension pneumothorax is the worst feared complication if left untreated.

The study arms included observation versus chest tube thoracostomy. Only 6% of patients failed observation and developed pneumothorax, including only 15% failed observation on positive pressure ventilation. In multivariate regression analysis, failure of observation was seen in patients with chest radiographic evidence of pneumothorax progression and symptoms of respiratory distress. According to this study, it is safe to closely observe trauma patients with occult pneumothorax on chest radiographs, even if receiving mechanical ventilation. [57]


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