A pneumothorax is air in the intrapleural space causing collapse of the lung. These can be spontaneous (primary pneumothorax in healthy patient with no underlying pulmonary pathology) or secondary (cause from underlying pulmonary pathology). Patients will typically present with sudden onset sharp, pleuritic chest pain on the side of the pneumothorax, associated with shortness of breath. On exam there is typically tachypnea, tachycardia, hypoxia, and decreased breath sounds on the affected side.
Chest x-ray is the primary work-up and will typically show absence of lung markings on the periphery of the pleural line. Ultrasound can also be used to diagnose pneumothorax by visualizing lack of lung sliding. CT chest is the gold standard for diagnosis of pneumothorax, however it is often unnecessary if pneumothorax is evidence on chest plain films.
Treatment of a pneumothorax will vary depending on the size and etiology. This module discusses needle aspiration of a pneumothorax, where a needle is inserted into the intrapleural space and air is aspirated to achieve re-expansion of the lung. This treatment is appropriate for a simple primary pneumothorax with only 15-30% collapse. A non-traumatic pneumothorax with less than 15% collapse can be treated with 100% oxygen, observation and a repeat chest x-ray. Tube thoracostomy is indicated in patients with penetrating trauma, blunt trauma, large pneumothorax >30%, secondary pneumothorax or tension pneumothorax.
- Confirmation of pneumothorax
- Anesthetization of superficial and deep tissue
- Estimation of tissue depth
- Insertion of catheter into pleural cavity
- Aspiration of pneumothorax
Needle aspiration of pneumothorax is done with a needle inserted anteriorly into the 2nd intercostal space on the side of the pneumothorax. The patient should be positioned in a semi-recumbent position to allow air to collect at the apex of the lung. The needle should be inserted on the superior aspect of the 3rd rib to prevent damage to the neurovascular bundle.
Needle aspiration is indicated for:
- Primary pneumothorax
- Pneumothorax with only 15-30% collapse
Absolute contraindications include tension pneumothorax and hemodynamically unstable patients. Relative contraindications include large pneumothorax and secondary pneumothorax.
Local anesthetic is used to numb the superficial and deep tissues overlying where the needle will be placed.
Patients can often be discharged after aspiration of primary pneumothorax. They should be observed and if the repeat chest x-ray 6 hours after the aspiration shows no recurrence of the pneumothorax, reliable patients may be discharged home with 24- and 48- hour follow-up with a primary care doctor. If pneumothorax does not re-expand within 1 week, patients may need follow-up with a cardiothoracic for further management.
If aspiration is unsuccessful, tube thoracostomy should be done and the patient should be admitted into hospital.
Common complications include inadequate drainage, infection, and bleeding. Less common complications include intercostal vessel bleeding and re-expansion pulmonary edema.
Needle Aspiration for Pneumothorax
- Rosen, Peter, John A. Marx, Robert S. Hockberger, Ron M. Walls, and James Adams. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby Elsevier, 2006. Print.
- Porcaro, William and Feldman, David. “Pneumothorax.” Rosen & Barken’s 5-Minute Emergency Medical Consult. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010. Print.
- Light, Richard W., MD. Primary spontaneous pneumothorax in adults. UpToDate, 6 August 2015. Web. 27 Nov 2015.