CLINICAL
Gallon A (1998) Pneumothorax. Nursing Standard. 13, 10, 35-39.
Alison Gallon MSc,
MCSP, is Superintendent
Respiratory
Physiotherapist, Norfolk
& Norwich Health Care
NHS Trust, Norwich.
KEY
WORDS
■ ACCIDENT AND
EMERGENCY
NURSING
■ LUNG DISEASE
These key words are based
upon work undertaken by
the RCN Library.
This article has
been subject to
double-blind review.
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Pneumothorax
This article discusses different types of pneumothorax and aspects of management,
including physiotherapy and the insertion and removal of chest drains.
Date of acceptance: October 7 1998.
A pneumothorax is the presence of air in the pleural
space. The lungs and thoracic cavities are lined by a
continuous mesothelial membrane (the pleura). The
visceral layer is intimately attached to the surface of
the lung while the parietal layer lines the chest wall.
They are held together by surface tension. This allows
the lungs and chest wall to move together as one and
the pleural ‘space’ is only a potential space. However,
if the integrity of either pleural layer is breached, air will
enter the pleural cavity and the lung will shrink down
towards the hilum (Figs. 1 and 2).
There are, basically, two types of pneumothorax
– spontaneous and traumatic – either of which can
develop into the life-threatening state of a tension
pneumothorax.
SPONTANEOUS PNEUMOTHORAX
Spontaneous pneumothoraces mostly occur in appar-
ently healthy people following the rupture of a sub-
pleural bleb (blister), usually in the apex of the lung.
The highest incidence is in those aged between 20 and
30 and is four to five times more common in males.
There are several conditions in which these blebs
tend to occur, the most common being Marfan’s and
Ehlers-Danlos’ syndromes. These connective tissue
disorders are associated with tall, thin people (Emer-
son 1981). Another, rarer, group of conditions, known
collectively as histiocytosis X, include Letterer-Siwe
disease, Hand-Schüller-Christian disease and
eosinophilic granuloma (Crofton and Douglas 1969).
Probably the rarest form of spontaneous pneumotho-
rax is catamenial, which occurs during menstruation
(though fortunately not every month).
Spontaneous pneumothoraces are more common
in patients with chronic lung disease such as asthma
and cystic fibrosis. Patients with emphysema, partic-
ularly those with bullae, have an even higher incidence
of pneumothorax. Many patients who develop
pneumothoraces are also smokers (Light 1993).
TRAUMATIC PNEUMOTHORAX
A pneumothorax can occur following blunt chest
trauma or a penetrating injury, such as a stab wound.
If a fractured rib or other sharp article penetrates the
parietal and visceral pleura and punctures the lung, a
pneumothorax can occur. Air can also enter the pleural
space due to a breach of the visceral pleura by high
pressures during mechanical ventilation. Another
NOVEMBER 25/VOLUME 13/NUMBER 10/1998 N U R S I N G S TA N D A R D 3 5
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common cause of secondary pneumothorax is
inaccurate insertion of a subclavian cannula.
TENSION PNEUMOTHORAX
A tension pneumothorax occurs when a tear to the vis-
ceral pleura remains unsealed and a valve is formed
so that air enters the pleural space on inspiration but
cannot leave on expiration. The pressure increases
rapidly, causing a life-threatening situation. Increasing
pressure displaces the mediastinum towards the oppo-
site side, causing cardiorespiratory distress, hypox-
aemia, systemic hypotension, shock and, ultimately,
cardiac arrest.
SIGNS AND SYMPTOMS OF PNEUMOTHORAX
The first sign is, usually, shortness of breath, which is
rapid in onset. The severity relates to the size of the
pneumothorax. Along with the dyspnoea, there is usually
pain which is often pleuritic in nature. Again, it is sudden
in onset and usually occurs in the lateral part of the chest
and may radiate to the shoulder, neck or epigastrium.
Rarely is the pain central. There is frequently a dry, irri-
tating cough, which may exacerbate the pain. Tachy-
cardia occurs with moderate or large pneumothoraces.
On auscultation, there would be quiet or absent
breath sounds on the affected side. The percussion note
would be hyper-resonant and tactile vocal fremitus
would be reduced. There would also be a reduction in
the movement of the chest wall on the affected side.
The chest X-ray (CXR) changes are classic (Figs.
3 and 4). The characteristic appearance is the sharply
defined lung border separated from the chest wall by
a clear zone absent of lung markings. If very shallow,
these features may only be visible on expiration. If very
large, the lung appears as a globular mass at the hilum
(Crofton and Douglas 1969).
When the pneumothorax is relatively small, it is
common for the initial dyspnoea and discomfort to
improve after a few hours – even if the CXR shows no
improvement. The degree of dyspnoea varies accord-
ing to the size of the pneumothorax and the condition
of the lungs. Even with a large pneumothorax (over 20
per cent collapse), it has been shown that an immedi-
ate fall in arterial oxygen saturation (SaO2) can return
to normal within a few hours if the lungs are relatively
healthy. This is because of hypoxic vasoconstriction,
which reduces the intrapulmonary shunt and improves
the ventilation/perfusion ratio.
CLINICAL

Fig. 1. A normal chest is on mechanical ventilation, there will be high airways

pressure and an expired minute volume less than pre-
set. Surgical emphysema could be the first sign and
may be felt in the neck. The auscultatory signs of a
Parietal Visceral
spontaneous pneumothorax will be present, but the
pleura pleura patient will be restless, anxious, pale and sweaty. A
nurse working in A&E, ITU or a trauma ward, may be
the first to recognise the presence of a tension pneu-
Apex mothorax and should be aware of patients at risk.

CURRENT MANAGEMENT
Tension pneumothoraces require emergency action.
The recommended treatment is a thoracocentesis, the
Base
needle being inserted into the second intercostal space
anteriorly. This can be followed by the insertion of an
intercostal drain when the patient is more stable.
If the pneumothorax is not under tension, the treat-
ment will depend on its size. Usually, a small one (less
than 10 per cent) can be left to heal itself (provided the
Mediastinal Intercostal
space muscle patient is asymptomatic). The air in the pleural space will
Rib gradually be absorbed and the two layers of pleura meet.
A moderate-sized (<20 per cent) pneumothorax
would be managed by needle aspiration. A pneu-
mothorax greater than 20 per cent, or causing dysp-
Fig. 2. A right pneumothorax noea, will require intercostal intubation. The usual site
to insert a chest drain is in the fifth intercostal space
in the anterior axillary line. Here, the chest wall is thin
and any small scar is subsequently hidden. The local
Parietal Visceral
anaesthetic needle is used to confirm that air can eas-
pleura pleura ily be aspirated at the site. A stab wound is then made,
Lung the chest drain inserted and connected to an under-
water seal drain (UWSD) (Figs. 5 and 6). A purse-
string suture will be inserted to close the track when
the drain is later removed.
Chest drains are invariably connected to an UWSD.
A chest drain is a large diameter (approx 14mm) plas-
tic tube with side holes at the patient end. It is inserted
into the pleural cavity and passes through the chest wall
down through a tight-fitting lid on the top of a chest drain
bottle. The tube goes virtually to the bottom of the bot-
tle where it is below a level of water, that is an under-
Pneumothorax
water seal. The chest drain bottle has a separate outlet
pipe above the water level which is either left open to
Mediastinal Intercostal the atmosphere or attached to suction. The purpose of
space musc le
the UWSD is to allow air to escape from the pleural
Rib
space but not re-enter. Air leaving the chest will be evi-
dent as bubbles escaping through the fluid level in the
chest drain bottle. If the air leak is very large, suction
SIGNS AND SYMPTOMS OF A TENSION PNEUMOTHORAX may need to be applied to the chest drain bottle so that
Recognition of a tension pneumothorax is crucial, as the volume of air taken out of the chest is greater than
treatment is required immediately. The patient will have the air leak. If the suction system does not achieve this,
cardiorespiratory distress and there will be shift of the it will not bring the lung into contact with the chest wall
mediastinum to the opposite side. Observations will and merely serve to perpetuate the leak (Emerson and
reveal a low blood pressure, an increased heart rate, McIntyre 1966).
a reduced Sa02 and an increased central venous pres- If the chest drain is left open to the atmosphere,
sure with distended neck veins. The apex beat will be air flow will be governed by the difference in
displaced to the opposite side, there will be tracheal intrapleural pressures and atmospheric pressure. If the
deviation and unequal chest movement. If the patient pressure in the pleural cavity is below atmospheric (for

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 Fig. 3. Large, right pneumothorax
Fig. 5. Pneumothorax with chest drain
Parietal Visceral
pleura pleura
Apical
drain
Mediastinal Intercostal
space musc le
Rib
example during inspiration), the water level will rise
slightly in the tube and when it is above atmospheric
pressure (such as during expiration), air will flow down
the tube pushing the water level in the tube down (Fig.
7). Suction pressures are subatmospheric (usually
between -0.7 and -4 kPa). If a patient is on suction,
the fluid level in the chest drain bottle does not rise and
fall with respiration.
How long the chest drain remains in situ depends
on how quickly the pneumothorax takes to heal. In
young patients with spontaneous pneumothoraces,
the drain usually stops bubbling within a day. Trau-
matic pneumothoraces may take a bit longer, espe-
cially if the patient is on intermittent positive pressure
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Fig. 4. Shallow, left pneumothorax
ventilation. Older patients, especially those with
emphysema, take much longer to re-expand the lung
and the chest drain may be in situ for several weeks.
When the air leak does stop and the CXR confirms
that the lung is fully inflated, a clamp is often applied
to the chest drain for 24 hours, but this is not recom-
mended. A repeat CXR will reveal whether or not the
lung has remained re-expanded. If there is no pneu-
mothorax, the chest drain will be removed. If,
however, there is recurrence of the lung collapse, the
chest drain has to stay in situ, unclamped, for a further
period of time.
Sometimes, high levels of inspired oxygen are
used for short periods to speed resolution by increas-
ing the absorption of pleural air fourfold (Light 1993).
MANAGEMENT OF CHEST DRAINS
The management of chest drains is extremely impor-
tant and is, in the main, the role of the nurse. There
are several routine observations and procedures that
are required, and an awareness of potentially danger-
ous situations. Chest drains need ‘milking’ at regular
intervals to ensure that they do not get blocked (usu-
ally by blood clots). The procedure involves using spe-
cialised rollers to compress the tube down its length.
As the rollers are released, a suction is created which
should clear any blockage.
Regular observation for air leaks is important. There
may be a continuous bubbling in the chest drain bottle
(if the patient is on suction). Alternatively, bubbling may
only occur on expiration (if not on suction). Absence or
presence of bubbling should be noted, as the tube may
be clamped or removed 24 hours after the last bubble
was seen. It may be that no bubbling is seen on normal
respiration. If that is the case, the patient should be
asked to take a deep breath and cough. If bubbles
appear, there is still an air leak, however small. Another
routine check should be at the site of insertion of the
chest drain. If a sucking noise is heard here, it could
CLINICAL
Fig. 6. Chest drain bottle
From chest drain in c hest wall
To suction or left
open to atmosphere
Calibrated scale in ml Fluid le vel in tube
Sterile water
mean that the chest drain has become dislodged (one
of the eyelets may be outside the chest wall) in which
case the air leak may not be from the lung.
Regular observation should be made of whether
or not the fluid level in the tube is fluctuating. If the level
does not rise and fall with respiration, the tube may be
obstructed or the lung may have re-expanded.
If the chest drain is on suction, regular and thorough
inspection of the system is essential. The suction unit
needs to be checked for the correct pressure. Check-
ing that it is also switched on is vital. A closed suction
system that is not working could give rise to a tension
pneumothorax and/or surgical emphysema. Checking
that the suction tubing is patent is also essential. It has
been known for a patient to move a chair onto the tub-
ing, leaving nowhere for the air to go but back into the
patient, again with life-threatening consequences.
It is also important to check that the chest drain
bottle is below the level of the patient’s chest. Raising
it above the level of the chest can result in syphoning
of the bottle’s contents into the pleural space. Some
patients have been known to put their chest drain bot-
tles on their lockers to make room for visitors.
If, for any reason, the chest drain, or any part of
it, becomes disconnected, urgent action is required.
If the chest drain comes out of the chest, the hole in
the chest wall must be covered immediately, usually
a finger will suffice, to prevent air getting into the
pleural cavity. If any part of the tubing becomes
disconnected, the chest drain should be clamped
immediately, the tubing reconnected and the clamp
removed.
Clamping of chest drain tubing should only be done
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Fig. 7. Movement of water level in tube
Fluid le vel
in tube
Inspiration
Fluid le vel
in tube
Expiration
to change drainage bottles or to lift bottles over beds.
The clamps should never be left on more than a few
moments where there is an air leak, as this could cause
surgical emphysema and/or tension pneumothorax.
PHYSIOTHERAPY FOR PNEUMOTHORACES
Physiotherapy for patients with pneumothoraces varies
according to the type and degree of pneumothorax. A
small to moderate lesion (<20 per cent), not requiring
intercostal drainage, would need no physiotherapy.
When air enters the pleural cavity, the elastic recoil of
the lung pulls it down towards the hilum, while the
chest wall springs outwards. The only way to resolve
the situation is to get both layers of pleura together.
Breathing exercises would merely expand the chest
wall. If the lung is not attached to it, no benefit would
accrue from ‘breathing exercises’.
If a patient needs an intercostal tube to drain his
or her pneumothorax, physiotherapy will be indicated.
Treatment is mainly based on mobilisation and posi-
tioning. Walking should be encouraged, with the
patient or physiotherapist carrying the chest drain bot-
tle well below the level of entry into the chest. If the
patient is attached to suction, he or she can walk on
the spot. Sometimes, if the suction is on a low level,
patients can be disconnected for short periods to
enable them to increase their ambulation.
Positioning of the patient to assist drainage of air
would be specific for each patient and determined by
the CXR. Lying on the side of the pneumothorax may
help to drain air through the intercostal tube. Tipping
the end of the bed so that the patient is lying head
down may help if the pneumothorax is apical. Posi-
 tioning in this way may also help to seal the leak and
facilitate lung expansion (Zidulka et al 1982).
Huffing and coughing will also assist drainage by
forcing air from the pleural space out through the
chest drain.
If the pneumothorax is due to chest trauma, for
example a stab wound, mobilisation should be partic-
ularly vigorous. Brisk walking up and down stairs or
running will assist drainage and re-expansion of the
lung (Senekal 1994). If the patient is restricted by suc-
tion tubing, mobilisation could take the form of step
exercises, running on the spot or using an exercise
bicycle.
In older patients with underlying lung disease,
breathing exercises and techniques to clear secretions
may be necessary, as the lung would be unable to re-
expand if retained secretions were blocking airways.
It is important to remember that having a chest
drain in situ is painful. Adequate analgesia should be
given to allow the patient to move about and comply
with physiotherapy (Crofton and Douglas 1969).
Because of the pain, patients are often reluctant to
move their arm on the side of the pneumothorax.
Every patient with an intercostal drain should maintain
full range of movement in the shoulder on the affected
side, whether by themselves or with the aid of the
physiotherapist.
Keeping the chest and trunk mobile is also impor-
tant. Often, exercising in front of a mirror will let them
see how bad their posture is and help them to correct
it. Having been shown what to do, most patients will
continue exercising on their own, providing that they
have sufficient analgesia. Some, however, will require
frequent reminding and here the nurse can help. Phys-
iotherapists can rarely spend long with these patients
and may only attend once a day. However, the nurse
will be able to spend more time with them and can
check that they are actually doing their exercises as
instructed.
Precautions for physiotherapists treating patients
with pneumothoraces include the avoidance of posi-
tive pressure techniques (such as intermittent positive
pressure breathing and continuous positive airways
pressure) in the absence of a chest drain. These tech-
niques may be used with care if an intercostal drain is
in situ. If the patient is ventilated, manual hyperinfla-
tion should be avoided if there is no chest drain. Again,
the technique can be used with care if a tube is pre-
sent and a watchful eye kept on the drainage bottle. If
there is any change in the nature of the drainage, for
example an increase in the air leak, manual hyperin-
flation should be stopped immediately and omitted
from any further treatments.
The physiotherapist will know that treatment has
been successful once normal breath sounds and per-
cussion note are heard and the patient has equal chest
movement.
REMOVAL OF CHEST DRAINS
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The removal of chest drains is, once again, the role of
the nurse, and it is very important to get the technique
right. Patients are usually given Entonox for analgesia
and instructed in deep breathing exercises. After three
or four breaths, the patient holds his or her breath on
a deep inspiration. During this time one nurse quickly
pulls the drain out while another ties the purse-string
suture. This technique is designed so that no air can
enter the pleural space during removal of a chest
drain. A check CXR will confirm whether or not the lung
is still re-expanded.
EFFECTIVENESS OF TREATMENT
Chest drainage remains the treatment of choice for
most pneumothoraces. However, a large number of
patients with spontaneous pneumothoraces will
develop another one at some stage. Young, fit patients
have about a 30 per cent chance of a recurrence and
after a second pneumothorax have a 70 per cent
chance of a third (Forrest et al 1991). Older patients
with chronic lung disease have a greater than 50 per
cent chance of a second pneumothorax (Emerson
1981). Physiotherapy may help to re-expand the lung
more quickly after a pneumothorax, but it cannot stop
another one recurring. Patients with recurrent pneu-
mothoraces will require pleurodesis, either chemically
or surgically, but the details of this treatment are
beyond the scope of this article ■
Acknowledgement
I would like to thank Mr BA Ross, FRCS, for his
invaluable advice in preparation for this article.
REFERENCES
Crofton J, Douglas A (1969) Respiratory Diseases. Oxford and Edinburgh,
Blackwell Scientific Publications.
Emerson P (1981) Thoracic Medicine. London, Butterworths.
Emerson DM, McIntyre JA (1966) A comparative study of the physiology
and physics of pleural drainage. Journal of Thoracic and Cardiovascular
Surgery. 52, 40.
Forrest AM et al (1991) Principles and Practice of Surgery. Edinburgh,
Churchill Livingstone.
Light RW (1993) Management of spontaneous pneumothorax. American
Review of Respiratory Diseases. 148, 245-248.
Senekal M (1994) The optimal physiotherapeutic approach to penetrating
stab wounds of the chest. South African Journal of Physiotherapy. 50,
29-36.
Zidulka A et al (1982) Position may stop pneumothorax progression in
dogs. American Review of Respiratory Disease. 126, 51-53.