Treatment of Pneumothorax

Therapy varies with the extent of the collapse and the nature and severity of the underlying disease.

A tension pneumothorax may emergently require drainage by needle thoracostomy. A small or even moderate-sized pneumothorax in an otherwise normal child may resolve without specific treatment, usually within about 1 wk. A small (<5%) pneumothorax complicating asthma may also resolve spontaneously.

Administering 100% oxygen may hasten resolution. Patients with chronic hypoxemia should be monitored closely during the administration of supplemental oxygen. Pleural pain deserves analgesic treatment. If there is >5% collapse or if the pneumothorax is recurrent or under tension, chest tube drainage is necessary.

Pneumothoraces complicating Cystic fibrosis frequently recur, and definitive treatment may be justified with the 1st episode, even with <5% collapse.

Closed thoracotomy (simple insertion of a chest tube) and drainage of the trapped air through a catheter, the external opening of which is kept in a dependent position under water, is adequate to re-expand the lung in most patients; pigtail catheters are frequently used.

When there have been previous pneumothoraces, it may be indicated to induce the formation of strong adhesions between the lung and chest wall by a sclerosing procedure to prevent recurrence. This can be carried out by the introduction of doxycycline or talc into the pleural space (chemical pleurodesis).

Extensive pleural adhesions help to prevent recurrent pneumothorax, but they also make thoracic surgery difficult. For conditions in which lung transplantation may be a future consideration (e.g., CF), a stepwise approach to treatment of pneumothorax has been proposed. If the patient is comfortable and the pneumothorax is small, no intervention is warranted. For a larger leak or one that does not resolve, simple thoracostomy tube drainage can be attempted. For continuing leak, or recurrence, the next step could be thoracoscopic blebectomy without pleural abrasion. Only after these steps have failed should the full aggressive pleural stripping and abrasion be undertaken.
Treatment of the underlying pulmonary disease should begin on admission and should be continued throughout the course of treatment directed at the air leak.