Alternative Treatments of Pneumothorax

Zachary D. Repanshek, MD; Jacob W. Ufberg, MD; Gary M. Vilke, MD; Theodore C. Chan, MD; Richard A. Harrigan, MD


J Emerg Med. 2013;44(2):457-466. 

In This Article

Abstract and Introduction


Background: Pneumothorax has traditionally been treated in the Emergency Department by tube thoracostomy. However, this is an invasive procedure with high risk of complication and prolonged hospitalization.

Discussion: In select settings, there are alternative forms of management of pneumothorax that carry lower risks and may reduce hospital stay. This article reviews the settings in which less invasive treatment, including observation alone, may be indicated. This article also reviews the techniques for simple aspiration and small-bore catheter insertion (by either Seldinger or catheter-over-wire technique) with Heimlich valve, as well as the indications, contraindications, and potential risks and benefits of each.

Conclusions: The practices of observation, simple aspiration, and small-bore catheter insertion with Heimlich valve for selected patients may decrease complications, time, and costs by avoiding invasive procedures and hospital admissions.


Pneumothorax, the presence of air in the pleural space leading to loss of negative intrathoracic pressure, is a commonly encountered condition in the Emergency Department (ED). The process may be spontaneous, traumatic, or iatrogenic, and if there is increasing pressure in the pleural space, one may develop a pneumothorax with tension physiology. Spontaneous pneumothorax may be further differentiated into primary, occurring in patients without underlying lung disease, and secondary, involving patients with any of a wide variety of parenchymal diseases. Traditionally, tube thoracostomy has been used as the treatment for pneumothorax in the ED. There are, however, less-invasive management alternatives, specifically in treating primary spontaneous pneumothorax (PSP).

The incidence of PSP is thought to be as high as 18 per 100,000 in males and 6 per 100,000 in females.[1] Risk factors for PSP include tall stature, thin body habitus, male gender, and smoking. There are also studies suggesting that pregnancy may be an additional risk factor, and a familial preponderance may be seen.[2,3] PSP has been shown to have lower rates of mortality and recurrence when compared to other types of pneumothorax.[4] For this reason, more conservative treatment, which may lead to a decrease in resource utilization and the need for, or duration of, hospitalization, may be considered in PSP, as well as a few other select pneumothorax scenarios.

Alternatives to tube thoracostomy in the ED include observation, simple aspiration, and small-bore catheter insertion; each will be discussed below.