Primary spontaneous pneumothorax refers to a pneumothorax occurring without trauma and without apparent underlying lung disease (e.g. COPD, Pneumonia, Interstitial lung disease, cancer).

See ER Treatment of Spontaneous Pneumothorax – Flow Chart from Credit Valley Hospital.

General Guidelines

• Patients who are asymptomatic (no respiratory distress) with pneumothoraces < 3cm from the apex can be managed conservatively with minimum symptomatology.
• For those with a pneumothorax > 3cm, use a small pigtail or pneumothorax catheter (8-14F) and either manually aspirate the air, attach to Heimlich valve, or attach to wall suction.
• Patients whose lungs remain expanded after 4-6 hours with a closed valve, may be safely discharged home after removing the tube. Alternatively, they can be discharged home with a closed tube and removed the next day if the lung remains expanded. All patient should receive a follow-up chest x-ray in 24h.
• Patient with lungs that re-collapse and only remain expanded with an open Heimlich valve can also be safely discharged home with an open Heimlich valve and a followup x-ray the next day.
• Patients with recurrent collapse and minimal improvement with aspiration or Heimlich value should be attached to continuous wall suction. Admission for observation should be considered in these scenarios.  A larger chest tube should be considered if the lung remains collapsed despite wall suction.

Pigtail or pneumothorax catheters

Tips for catheter placement (see ‘triangle of safety’):

1. Place in the ant-midaxillary line, 4^th/5^th intercostal space.
2. Behind the pectoral fold where there is less soft tissue
3. Go higher than you think. Avoid low placement especially on the left side and in patients with cardiomegaly
4. Can also be placed in the midclavicular line 2^nd intercostal space (cosmetic risks higher)

• Age>50 and have a significant smoking history
• Presence of effusion / hemothorax
• Patient requiring larger sized chest tube and suction
• Patients requiring continuous suction to remain expanded
• Unreliable patients or those unwilling to return for follow-up

• Significant lung disease on exam or chest x-ray
• Persistent pneumothorax despite chest tube / persistent air leak
• Tension / bilateral pneumothoraces

Refer to Regional Thoracics Service (Vancouver General Hospital, Surrey Memorial Hospital, Kelowna, Royal Jubilee) for any of the above (3) indications. Patient will likely be offered surgery.

• All patients discharged home should receive a repeat x-ray in 24h to look for recurrent pneumothorax or subcutaneous air. They should receive daily chest x-rays until there is no recurrence of the pneumothorax.
• Patients with a persistent pneumothorax after 48 hours, should receive a CT scan to look for bullae and be referred to a Regional Thoracics Service for possible surgical intervention
• Pilots, divers, those with recurrent pneumothorax, or those that live in remote sites, should be referred to a thoracic surgeon as an outpatient.
• Some guidelines suggest waiting 14 days before flying, however a consult with a thoracic surgeon is advised if the patient is anticipating flying.

• Small pneumothorax <3cm
• Re-expanded lung that remains re-expanded after 4 hours with a closed valve (may remove tube the same day)
• Re-expanded lung that only remains re-expanded with an open Heimlich valve (lung collapses after valve is closed)
• All patients discharged should be able to quickly and safely return to the hospital if their symptoms recur
• Patients should be able to return the next day for follow-up

1. ER Treatment of Spontaneous Pneumothorax – Flow Chart. Credit Valley Hospital.

   
   

2. BTS Pleural Disease Guideline

   
   

3. ER Treatment of Primary Spontaneous Pneumothorax. Credit Valley Hospital Clinical Practice Guideline.

   
   

4. Chest Tube Placement (Video by EM:RAP)

   
   

1. Hassani B, Foote J, Borgundvaag B. Outpatient management of primary spontaneous pneumothorax in the emergency department of a community hospital using a small-bore catheter and a Heimlich valve. Acad Emerg Med. 2009 Jun;16(6):513-8. doi: 10.1111/j.1553-2712.2009.00402.x. Epub 2009 May 11.

   
   

2. Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, Luketich JD, Panacek EA, Sahn SA; AACP Pneumothorax Consensus Group. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001 Feb;119(2):590-602.