See also

Thoracocentesis and chest drain insertion

Background

• Primary spontaneous pneumothorax (PSP) is a pneumothorax occurring in patients without underlying lung disease and in the absence of provoking factors such as trauma, surgery or mechanical ventilation
• Secondary pneumothoraces may be harder to manage and have greater consequences. Advice from a respiratory physician or surgeon should be sought  

Assessment

Most episodes occur at rest. Consider PSP in patients with the following;  

Symptoms

• Acute onset chest pain – severe and/or stabbing pain, radiating to ipsilateral shoulder and increasing with inspiration (pleuritic)
• Sudden shortness of breath
• Anxiety, cough and vague presenting symptoms (eg general malaise, fatigue) are less commonly observed  

Signs

• General appearances may be normal
• Sweating, tachypnoea, tachycardia (most common finding)
• Splinting of the chest wall to relieve pleuritic pain
• Decreased or absent breath sounds
• Hyperresonance on percussion
• Asymmetric lung expansion, mediastinal and tracheal shift with large pneumothorax

Signs of tension pneumothorax

• Deviation of the trachea to the contralateral side, tachycardia, hypotension, cyanosis
• This is a medical emergency requiring urgent needle thoracocentesis (see thoracocentesis and chest drain insertion)

Imaging studies

• Chest radiograph – confirms pneumothorax
  Standard erect film in inspiration. Expiratory films are not required
  • A linear shadow of visceral pleura with lack of lung markings peripheral to it indicates collapsed lung
  • Flattening or inversion of the diaphragm on the affected side
  • Mediastinal shift toward the contralateral side
  • Small pleural effusions are commonly present
  • If chest radiograph is taken in supine position, signs of pneumothorax include:
    • Deep sulcus sign; lucency along the costophrenic angle is abnormally deepened
    • Hyperlucency of the affected side
      
      
• CT scan is not recommended routinely
  
  
• Measuring size of the pneumothorax
  • Measurement of pneumothorax size is controversial and not age-specific
  • The size of the pneumothorax is less important than the degree of clinical compromise
  • For children >12 yrs only, a pneumothorax is considered ‘large’ based on the following measurements (see diagram below)
    • Measurement of the vertical distance between the lung and thoracic cage at the apex. If >3 cm, pneumothorax is large⁴
      
      OR
      
      
    • Measurement of the distance between the lateral lung edge and chest wall at the level of the hilum; >2 cm = (at least 50%)

Management

See Algorithm

* Significant symptoms

• Significant breathlessness
• Hypoxia
• Pain  

** For the following groups of patients, consult for further advice.

• Age <12 yrs: may have less reliable reporting of symptoms and size calculations may not be applicable
• Secondary pneumothorax
  • Underlying lung disease eg Cystic Fibrosis, chronic neonatal lung disease, asthma
  • Trauma or thoracic surgery
  • Positive pressure ventilation
  • Foreign body inhalation
  • Evidence of tension pneumothorax – see thoracocentesis and chest drain insertion guideline 

Consider consultation with local paediatric team when 

• Large pneumothorax
• Significant symptoms  

Consider transfer when

• Need for ongoing drainage or underwater seal drainage
• Deterioration during observation
  
  For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.  

Consider discharge when

• Minimal symptoms and no deterioration during period of observation
• Appropriate follow up arranged
• Appropriate education regarding recurrence rate after PSP (50-61%) and recognition of symptoms