Pneumothorax - Treatment of a

Publication: 17/04/2019  
Next review: 07/01/2025  
Standard Operating Procedure
CURRENT 
ID: 5965 
Supported by: Respiratory Dept
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Treatment of a Pneumothorax

GUIDELINES FOR TREAMENT OF PNEUMOTHORACES

  1. Introduction
  2. Treatment algorithms
    • Primary pneumothorax
    • Secondary pneumothorax
  3. Procedures
  4. Care of the chest drain
  5. Suction
  6. Removal of the chest drain
  7. Indications for referral for surgery

Introduction

Pneumothorax is defined as air in the pleural space.
Treatment options include observation, aspiration or intercostal drain insertion. This depends on

  • The size of the rim between the lung margin at level of hilum and the chest wall (small <2cm, large ≥ 2cm)
  • Underlying lung disease
    Primary pneumothorax when there is no underlying lung disease
    Secondary pneumothorax when there is pre-existing lung disease e.g. COPD (these are often more difficult to treat and are less likely to respond to aspiration only). If no known history of COPD assume if patient is >50 years with a significant smoking history.
  • Patients symptoms

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Aspiration of a Pneumothorax

Assumes competent operator/supervisor - if not trained please contact the Respiratory Registrar for advice on bleep.6775

  1. Explain procedure to the patient and document written consent
  2. Mark correct site and side
  3. Make sure they are comfortable, sitting at an angle of 45 degrees against some pillows (ideally in a pleural procedure room)
  4. Consider premedication with opiates.
  5. Sterilise the chest wall with cleaning fluid.
  6. Choose the second intercostal space in the midclavicular line anteriorly on the affected side (check CXR) or in the triangle of safety (lateral edge of pectoralis major, lateral edge of latissimus dorsi, inferiorly by the line of the fifth intercostal space and superiorly by the base of the axilla)
  7. Infiltrate the skin and subcutaneous tissues down to the pleura just above the superior aspect of the rib with lignocaine. You should be able to aspirate air when in the pleural space.
  8. Using a Pleural aspiration kit advance the plastic catheter and needle through the anaesthetised track. When air is aspirated hold the needle steady and advance the plastic sheath. Then withdraw the needle.
     Attach a 50ml syringe with a three-way tap to the end of the cannula to expel the air aspirated. When procedure is completed remove catheter and apply a dressing.
  9. Aspirate air until any of the following occur
    • You meet resistance
    • The patient develops pain or excessive coughing
    • You aspirate more that 2500mls (50x50) which signifies an on-going air leak.
  10. Repeat CXR to assess response (if pneumothorax small or resolved the procedure has been successful)
  11. Reasons for lack of success can be
    • A persisting air leak 
    • Technical reasons such as kinking of the cannula or withdrawal from pleural space (in this case repeating the procedure may be worthwhile).
  12. If discharging patient arrange chest clinic appointment within 7 to 10 days, warning patient to return if they develop recurrent symptoms.

If the patient develops a tension pneumothorax as suggested by cardiovascular collapse then you must immediately insert a cannula into the 2nd intercostal space and leave this in place until a functioning chest drain has been placed.

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Insertion of a Chest drain for a Pneumothorax

Assumes competent operator/supervisor - if not trained then please contact the Respiratory Registrar for advice on bleep 6775. Other specialties trained to insert chest drains usually include the Emergency Department, Intensive care, Radiology and Cardiothoracic Surgery.

For the procedure you will need

Cleaning fluid
Gown and gloves
10 to 20 ml of 1% lignocaine
Suture
Seldinger chest drain kit (with syringes, needles, scalpel blade, drape,dressing)
Connecting tubing
Chest drain bottle
Sterile water for under water seal

  1. Explain procedure to patient and document written consent (unless emergency). Ideally give a copy of patient information about chest drains before procedure for them to read - Appendix 1
  2. Ideally this should be done in a pleural procedure room e.g the day room at the end of J12
  3. Ensure that they are comfortable leaning against pillows at 45 degrees and have an assistant to help you with the procedure. Mark the correct side and site - check the CXR
  4. Consider premedication with opiates, (all patients should be cannulated).
  5. Ensure the oxygen and suction are in working order prior to commencing.
  6. Sterilise the chest wall with cleaning fluid.
  7. Insert drain within the triangle of safety (p.3) on the affected side.
  8. Infiltrate the skin and subcutaneous tissues down to the pleural space where you will be able to aspirate air.
  9. Insert the seldinger chest drain as per the instructions contained in the kit.

Briefly
https://vimeopro.com/rocketmedical/rocket-medical-clinical-training-video/video/91933675

  1. Using the needle and syringe locate the pleural space by aspirating air and then pass the guide wire down the needle
  2. Remove the needle
  3. Make an incision in the skin about the size of the chest drain you are about to insert (12 to 20F)
  4. Use the dilators to make a tunnel through the subcutaneous tissue
    Do not put dilators all the way in - just until proximal end of bevel is into the into the pleural space
  5. Finally insert the chest drain and remove the guide wire and internal dilator.
  6. Attach the chest drain to the underwater seal bottle and tubing
  7. Ensure the drain is swinging (and bubbling at least initially).
  8. Secure the drain with a stitch (not a purse string)
  9. Apply a keyhole dressing with semi- occlusive dressing over the top
  10. Prescribe analgesia for the patient
  11. Repeat CXR
  12. Fill in chest drain insertion form - Appendix 2

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Care of the chest drain- pneumothorax

  1. Observations of pulse, temperature, blood pressure and oxygen saturations should be performed pre and post procedure and at least 6hrly thereafter.
  2. Explain safe handling of the drain to the patient and please give a patient information leaflet
    • The bottle should never be raised above the level of the tube insertion or water may enter the pleural space
    • The patient can mobilise if drain kept below waist level
    • To inform nursing staff immediately if any part of the drain becomes disconnected.

A chest drain for a pneumothorax should never have 3 way tap closed or clamped

  1. The drain should be observed for swinging and bubbling each shift and documented in the chest drain observation sheet. A chest drain that is not swinging is not functioning and the doctor should be alerted to this and should check for kinks, displacement from the pleural space or blockages (by flushing the drain with 20mls of saline).
  2. The dressing should be inspected each day and changed if necessary.

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Suction

  1. Suction may be used in a non-resolving pneumothorax (after about 48hrs) after discussion with a respiratory physician. There is little evidence however for this treatment
  2. Suction must be done only through a specially adapted wall mounted thoracic suction device (high volume, low pressure) and only by nurses trained to do so.
  3. Pressure of -10 to -20cm H20/-1 to -2 kPa should be used depending on patient comfort
  4. It is acceptable to disconnect the suction for short periods such as going for CXR or using the bathroom.
  5. If suction is to be stopped, the tubing connecting the suction device to the bottle must be removed or the drain is essentially a ‘closed system’ and will act as if the drain has been clamped.

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Removal of the chest drain

  1. Usually at least 24hrs after the drain has stopped bubbling and the CXR shows re-expansion of the lung.
  2. Sterilise around the drain with cleaning fluid
  3. Smaller seldinger drains do not usually require a suture. Infiltrate the wound edges with lignocaine if large bore chest drain used and needs a suture.
  4. Remove drain in one steady movement
  5. Apply simple dressing
  6. Repeat CXR
  7. Inform nursing staff so the patient can be monitored for breathlessness

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Referral for surgery

  1. Non- resolving pneumothorax after approximately 3-5 days (in patient)
  2. Second ipsilateral pneumothorax
  3. First contralateral
  4. Bilateral spontaneous
  5. Spontaneous haemothorax
  6. Professions at risk e.g. pilots, divers

Provenance

Record: 5965
Objective:
Clinical condition:

Pleural diseases

Target patient group: Those with pleural conditions
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010

Document history

LHP version 1.0

Related information

Not supplied

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