Emergency Department NUH

Pneumothorax

This pathway is only for management of spontaneous pneumothorax ie not related to trauma
Primary pneumothorax = no underlying lung disease
Secondary pneumothorax = underlying lung disease (eg COPD, asthma, TB, malignancy, age > 50 years and
significant smoking history, evidence of underlying lung disease on exam or CXR)

Contraindications to needle aspiration Technique Safe Triangle

· Signs of tension pneumothorax Staff must be competent or supervised by person Between lateral edges of pectoralis major
· Haemodynamically unstable competent in procedure and latissimus dorsi, above the 5th
· Bilateral pneumothoraces intercostal space and below the base of
· Previous pneumothorax within last 2 BEWARE BULLAE the axilla
weeks
· Complete NatSIP checklist & document consent
· Anticoagulated - await INR unless
· Aseptic technique
emergency
· Site: Safe triangle (unless contraindicated eg
· Ventilated patient
extensive scarring – then use 2nd space anteriorly)
· Aspiration: 14 – 16 G cannula, stop when no more
air can be aspirated or 2.5 L aspirated
· Drain: 8 -14 Fr, take care when inserting dilator;
aim drain upwards
· Immediate repeat CXR

Primary Pneumothorax Secondary Pneumothorax

No DIB DIB DIB No DIB No DIB

AND AND / OR AND / OR AND AND
< 2cm rim of air on CXR > 2 cm rim of air on CXR > 2 cm rim of air on CXR 1 – 2 cm rim of air on < 1 cm rim of air on CXR
(measure at level of hilum) (unless senior decision to CXR
observe only)

Put onto high flow oxygen unless COPD) in which case given oxygen to target sats to 88-92%

Contraindications to Contraindications to
Yes Yes
needle aspiration? needle aspiration?

No No

Consider needle aspiration Consider needle aspiration

(50% success rate) (50% success rate)

Aspiration adequate? Aspiration adequate?

breathing improved, rim < 2 cm
(do not repeat aspiration unless
technical difficulties)
Yes
No breathing improved, rim < 1 cm
No
(do not repeat aspiration unless
technical difficulties)

Admit CDU
Insert Seldinger Chest Drain Yes
Prescribe O2
Complete procedure checklist
PRN analgesia
Check CXR after insertion
Observe 2 hours

Is patient suitable for discharge?

Remains asymptomatic for 2 hours Secondary Pneumothorax: Admit
Refer to Medical reg bleep 4627
Yes

Discharge Primary Pneumothorax with chest drain: Admit to CDU

Refer to Chest clinic
· Complete OPA referral form including patient contact · Observe for bubbling every hour – document when stops
phone number · Observe for 4 hours from when bubbling in drain stops
· Print discharge letter for notes · Repeat CXR at 4 hours from when bubbling stops, prior to removing drain
· If CXR normal and no DIB, remove drain and observe for further 1 hour
Ensure patient has the following: · Discharge with advice and chest clinic OPA
· Copy of GP letter
· Patient advice leaflet Refer to Medical SpR if:
· Bubbling persists for more than 4 hours
Discharge advice (Give patient advice sheet):
· Persisting DIB
· Return immediately if breathless or chest pain
· Bubbling restarts within 4 hours of stopping
· Avoid diving – for life
· Persisting pneumothorax on check CXR
· Avoid air travel until further advice in chest clinic
· Surgical emphysema

DO NOT CLAMP DRAIN

EM Network Guideline Group v6 July 2018 [review July 2021]

 Emergency Department NUH
Pneumothorax

Lead Author

Consultant Emergency Medicine

Co-Authors / Collaborators

Consultant Respiratory Medicine

Reference Documents

Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline

2010. Thorax 2010; 65 (Suppl 2):ii18-ii31. doi:10.1136/thx.2010.136986
Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010.
Thorax 2010; 65 (Suppl 2):ii61-ii76. doi:10.1136/thx.2010.137026

EM Network Guideline Group v6 July 2018 [review July 2021]