What is the initial emergency department (ED) care for iatrogenic and traumatic 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

Aspiration is the technique of choice for iatrogenic pneumothoraces, because recurrence is usually not a factor. Tube thoracostomy is reserved for very symptomatic patients.

In general, traumatic pneumothoraces should be treated with insertion of a chest tube, particularly if the patient cannot be closely observed. Chest tubes are attached to a one-way valve apparatus that uses a water chamber to avoid a direct connection to atmospheric pressure (so that during inspiration, when negative pressure is generated, air does not rush into the pleural space) and allows for the continuous removal air from the pleural cavity during respiration. Changing the pressure above the water seal allows for below atmospheric suction to further remove air from the pleural space. The collapsed lung reexpands and heals, thereby preventing continued air leakage. After air leaks have ceased for 24 hours, the vacuum may be decreased and the chest tube removed.

The process of lung reexpansion and healing is not immediate and may be complicated by pulmonary edema; therefore, a chest tube is usually left in place until the clinical conditions are met; any complications warrant longer placement.

A subset of patients who have a small (<15-20%), minimally symptomatic pneumothorax may be admitted, observed closely, and monitored by using serial chest radiographs. In these patients, administration of 100% oxygen promotes resolution by speeding the absorption of gas from the pleural cavity into the pulmonary vasculature.

Although commonly used, few data exist in the medical literature showing the efficacy of the procedure or reviewing the field-use and incidence of the needle decompression.


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