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Pneumothorax Types: A Quick Review

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Contact Hours: 5

This online independent study activity is credited for 5 contact hours.

Course Purpose

The purpose of this course is to provide healthcare professionals with a brief overview of traumatic and atraumatic pneumothorax, their signs and symptoms, treatment options for pneumothorax, and chest tube management.

Overview

Pneumothorax is also called a collapsed lung. When air enters the pleural cavity (the space between the lung and chest wall), the buildup of air puts pressure on the lung. The pressure decreases the lung’s ability to expand and recoil with inspiration and expiration, resulting in lung collapse. The development of pneumothorax can be life-threatening and may require rapid interventions. This course will discuss traumatic and atraumatic pneumothorax, their signs and symptoms, treatment methods, and chest tube management.

Course Objectives

Upon completion of the independent study, the learner will be able to:

  • Describe the tension pneumothorax
  • Describe atraumatic pneumothorax, and the various types of pneumothorax within the classification.
  • Recognize common signs and symptoms of pneumothorax.
  • Understand treatment options for pneumothorax.
  • Understand chest tube management for a patient diagnosed with pneumothorax.

Policy Statement

This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.

Disclosures

Fast CE For Less, Inc. and its authors have no disclosures. There is no commercial support.

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Definitions
Catamenial PneumothoraxA spontaneous pneumothorax that recurs during menstruation, within 72 hours before or after the onset of a cycle. It usually involves the right side of the chest and right lung and is associated with thoracic endometriosis.
Chest Drainage Unit (CDU)Used to reestablish normal lung function by incorporating three basic chambers: collection chamber, water-seal chamber, and suction mechanical regulator to control suction and help re-expand a lung.
Chest TubeA hollow, flexible tube that is placed into the chest and acts as a drain. 
Hamman Crunch (Hamman Sign)A crunching, rasping sound, synchronous with the heartbeat, heard over the precordium in spontaneous mediastinal emphysema. It is felt to result from the heart beating against air-filled tissues
Iatrogenic PneumothoraxOccurs when air enters the pleural space during a medical treatment or procedure.
Langerhans Cell HistiocytosisA rare disorder that affects children and adults, causing abnormal growth of immune cells.
Lymphangioleiomyomatosis (LAM)A lung disease caused by the abnormal growth of smooth muscle cells, especially in the lungs and lymphatic system. 
Marfan SyndromeA genetic disorder that affects connective tissues (tissue that supports skeleton and internal organs). It commonly affects eyes, heart, blood vessels and skeleton.
MediastinumAn area found in the midline of the thoracic cavity, which is surrounded by the left and right pleural sacs. It is divided into the superior and inferior mediastinum, of which the latter is larger.
Pleural Space (Pleural Cavity)  A fluid filled space that surrounds the lungs. It is found in the thorax, separating the lungs from its surrounding structures such as the thoracic cage and intercostal spaces, the mediastinum, and the diaphragm. 
Pneumocystis Pneumonia (PCP, Pneumocystis Jiroveci Infection)  A form of pneumonia that is caused by the yeast-like fungus Pneumocystis Jiroveci
PneumothoraxA collapsed lung that occurs when air leaks into the space between the lung and chest wall. 
SarcoidosisA condition in which there is an abnormal collection of inflammatory cells that form clumps in the lungs, skin, or lymph nodes.
Secondary Spontaneous Pneumothorax (SSP)A spontaneous occurrence of air in the pleural space in patients with underlying lung disease.
Seldinger TechniqueAn over-wire technique of catheter insertion to obtain safe percutaneous access to vessels and hollow organs.
Subcutaneous EmphysemaA condition in which air becomes trapped under the subcutaneous layer of the skin. 
Tension Pneumothorax  A life-threatening condition caused by the continuous entrance and entrapment of air into the pleural space, thereby compressing the lungs, heart, blood vessels, and other structures in the chest. 
Traumatic PneumothoraxAir in the pleural space that results from trauma and causes partial or complete lung collapse.
Video- Assisted Thoracoscopic Surgery (VATS)A minimally invasive surgical technique used to diagnose and treat problems in the chest. 
Introduction

A pneumothorax is a collection of air inside the pleural cavity.1 It can also be defined as the air inside and outside the lung that is caused by excess pressure on the lung, often from trauma, causing communication through the chest wall, or from lung diseases, such as whooping cough, cystic fibrosis, asthma, and chronic obstructive pulmonary disease (COPD).1,2 The air accumulates inside the chest between the parietal and visceral pleura, which applies pressure on the lung and cause it to partially or completely collapse.1,3

This course will discuss traumatic and atraumatic pneumothorax, their signs and symptoms, treatment methods, and chest tube management.

Defining Pneumothorax

Pneumothorax is also called a collapsed lung.4 When air enters the pleural cavity (the space between the lung and chest wall), the buildup of air puts pressure on the lung. The pressure decreases the lung’s ability to expand and recoil with inspiration and expiration, resulting in lung collapse.4 The development of a pneumothorax can be life-threatening and may require rapid interventions.4 The interventions to treat a pneumothorax depends on the size of the air sac in the pleural space, the pressure it exerts on the lungs, and its hemodynamic effects.4

Types of Pneumothorax

There are several types of pneumothorax all differing in their causes, signs, and symptoms. Typically, pneumothorax is divided into two main categories; traumatic and atraumatic.1 Atraumatic pneumothorax is further divided into primary and secondary pneumothorax.1 In addition to these, there are other types that will be discussed below.

Traumatic Pneumothorax

Traumatic pneumothorax is caused by air in the pleural space , resulting in partial or completed lung collapse from penetrating or blunt force trauma.,5 Penetrating trauma includes stab wounds, bullet wounds, and impalement, and blunt trauma includes a rib fracture, increased intrathoracic strain, and bronchial rupture.

Traumatic pneumothorax is caused by the following:1,5

  • Flying or diving
  • Penetrating wounds that are medial to the nipples or the scapulae could transverse the mediastinum
  • Rib fracture
  • Severe blunt trauma of the tracheobronchial tree

Signs and Symptoms

The following are some of the common signs and symptoms associated with traumatic pneumothorax:5

  • Dyspnea
  • Hamman sign or Hamman crunch is a characteristic crunching sound produced when air enters the mediastinum and is synchronous with the heartbeat.
  • In larger pneumothorax, diminished breath sounds and affected hemithorax hyperresonant to percussion are noticed
  • Pleuritic chest pain
  • Subcutaneous emphysema causes a crackle or crunch when palpated
  • Tachycardia
  • Tachypnea

It is important to note that these signs are not always present and are difficult to detect in a noisy setting.5 Moreover, the evidence can be localized to a small area or a large portion of the chest wall.5

Tension Pneumothorax

In tension pneumothorax, a one-way valve is created in the pleural space, which allows air to enter the lung, but does not let it flow out. 1,5,12 As a result, the trapped air accumulates, compresses the lung, and increases intrathoracic pressure that decreases venous return to the heart and causes shock and hemodynamic collapse.12 Tension pneumothorax may be caused by the following: 12

  • Failed central venous cannulation
  • Mechanical ventilation
  • Penetrating wounds
  • Simple pneumothorax with lung injury that fails to seal the blunt force trauma.

Signs and Symptoms

The initial signs and symptoms of tension pneumothorax are like simple pneumothorax, however, as the intrathoracic pressure increases, more symptoms may develop.12 The following are some of the common signs and symptoms associated with tension pneumothorax:12

  • Hypotension
  • Neck vein distention
  • The affected hemithorax is hyperresonant to percussion and feels tensed, distended, and poorly compressible to palpation
  • Tracheal deviation

Iatrogenic Pneumothorax

Iatrogenic pneumothorax is a subset of traumatic pneumothorax and is caused by invasive medical procedures like transthoracic needle aspiration, thoracentesis, central venous catheter placement, positive pressure ventilation, mechanical ventilation, and cardiopulmonary resuscitation.3,11 The risk of iatrogenic pneumothorax depends on the number of invasive procedures conducted. Procedures, in combination with limited access to internal jugular sites when a non-femoral vein site is desired, can cause an increased risk for iatrogenic pneumothorax.11

Any procedure which is done in proximity to the abdomen, especially the thorax, can lead to iatrogenic pneumothorax.11 This most commonly occurs when healthcare professionals place a subclavian catheter using landmarks without an ultrasound.11 The following technical errors can result in iatrogenic pneumothorax:11

  • Aiming the needle at the cephalad
  • Failing to keep the needle in place for the wire passage
  • Improper needle insertion position
  • Inadequate landmark identification
  • Taking a shallow trajectory with the needle
  • Using periosteum for insertion of the needle

Signs and Symptoms

Signs and symptoms depend on the size of the pneumothorax, and health of the lung.11 The following are some of the common signs and symptoms associated with iatrogenic pneumothorax:11

  • Absent or decreased breath sounds on the affected side
  • Dyspnea
  • Pleuritic chest pain
  • Tachycardia
  • Tachypnea
Atraumatic Pneumothorax

There are two subtypes of atraumatic pneumothorax:  primary and secondary spontaneous pneumothorax.

Primary Spontaneous Pneumothorax (PSP)

In the United States, the prevalence and incidence of primary spontaneous pneumothorax are 7 per 100,000 males and 1 per 100,000 females per year.1,6 It is caused without any known elicit event and in patients with no underlying pulmonary disease.1,3 Primary spontaneous pneumothorax typically occurs in tall, thin males who smoke.1,6 It typically occurs in males who are 20 to 30 years of age, and the condition has the highest recurrence rate in the first 30 days.1,6 Although it is a condition that typically affects young adults, it is a benign condition that  resolves in most cases.6 Risk factors and causes of PSP include:1,3,6

  • 20 to 30 years old
  • Familial pneumothorax
  • Marfan syndrome
  • Smoking
  • Spontaneous rupture of subpleural apical blebs or bullae
  • Tall thin body habitus in an otherwise healthy person

Primary spontaneous pneumothorax can occur while resting, during physical activities like stretching or reaching, or during diving or flying.3

Signs and Symptoms

Primary spontaneous pneumothorax patients may be asymptomatic or have minimal symptoms.6 The symptoms also depend on the size and proportion of the air sac or pneumothorax.6 The following are some of the common signs and symptoms associated with PSP:6

  • Dyspnea
  • Ipsilateral decreased breath sounds on auscultation
  • Percussion hyperresonance
  • Pleuritic chest pain
  • Shortness of breath
  • Thoracic hyperextension    

Secondary Spontaneous Pneumothorax (SSP)

Secondary spontaneous pneumothorax can occur in patients after an underlying pulmonary disease is diagnosed.1,3 It is more severe than primary spontaneous pneumothorax because it occurs in patients whose underlying pulmonary disease affects their pulmonary reserve.3 This form of spontaneous pneumothorax usually occurs in older patients aged 60 or above.1 The risk of SSP increases with smoking and is 102 times higher in smokers than non-smokers.1

As compared to primary spontaneous pneumothorax, secondary spontaneous pneumothorax has higher recurrence rates and lengthier hospital stays.7 The following are the underlying pulmonary diseases associated with secondary spontaneous pneumothorax:1,3,6,7

  • Acute respiratory distress syndrome (ARDS)
  • Asthma
  • Bronchogenic carcinoma
  • Chronic obstructive pulmonary disease (COPD)
  • Collagen vascular disease
  • Cystic fibrosis
  • Inhalational drug use like cocaine or marijuana
  • Langerhans cell histiocytosis
  • Lung cancer
  • Lymphangioleiomyomatosis
  • Marfan syndrome
  • Necrotizing pneumonia
  • Pneumocystis Jiroveci infection
  • Pneumocystis pneumonia
  • Pulmonary fibrosis
  • Sarcoidosis
  • Systemic sclerosis
  • Thoracic endometriosis
  • Tuberculosis

Signs and Symptoms

The following are some of the common symptoms associated with secondary spontaneous pneumothorax:8

  • Absent breath sounds
  • Acute dyspnea
  • Decreased tactile fremitus
  • Hyperresonance on percussion
  • Increased work of breathing
  • Jugular venous distension
  • Pulsus paradoxus
  • Reduced movement of the chest wall
  • Sharp, pleuritic chest pain
  • Tachycardia

Catamenial Pneumothorax

Catamenial pneumothorax is a rare form of secondary spontaneous pneumothorax that affects women and occurs within 48 to 72 hours of the onset of menstruation in premenopausal women. Although rare, it can also happen in postmenopausal women taking estrogen.3,9 Women can experience recurrent episodes of pneumothorax, however, the exact cause is unknown.3,9 Catamenial pneumothorax is a rare disease, with only 3 to 6% of spontaneous pneumothorax cases being catamenial pneumothorax.10

There are several theories about the causes of catamenial pneumothorax, and researchers believe that the answer lies in metastatic, hormonal, and anatomical abnormalities.9 For instance, in the metastatic model, the endometrial tissue’s abnormal migration from the lining of the uterus or other body areas, such as the diaphragm or the pleural space, is thought to be the cause of catamenial pneumothorax.9 In the anatomical model, the absence of a cervical mucous plug during menstruation allows the air to enter the pleural space from the genital tract, and in the hormonal model, the hormone, prostaglandin F2 causes the bronchioles within the lungs to become narrow, which in turn causes the air sacs to rupture and air to be trapped in the pleural space.9

Signs and Symptoms

The following are some of the common signs and symptoms associated with catamenial pneumothorax:10

  • Chest pain
  • Cough
  • Dyspnea
  • Hemoptysis
  • History of spontaneous pneumothorax or catamenial hemothorax
  • Scapular or thoracic pain before or after menstruation
  • Shortness of breath
Treatment and Interventions

Treatment and management depend on the clinical scenario and are different for each type.1

Traumatic Pneumothorax

Most pneumothorax are treated by inserting a chest tube into the 5th or 6th intercostal space anterior to the midaxillary line.5 Although chest tubes are effective, they require an invasive medical procedure that extends hospital stays, increases morbidity, and leads to complications like infection, re-expansion pulmonary edema, and malpositioning.13

Following are the two ways of traumatic pneumothorax management:5,13

Needle Decompression

Needle thoracostomy is used for emergent decompression of the chest.13 According to the American College of Chest Physicians, an angio-catheter should be placed in the second intercostal space at the midclavicular line.13 However, a patient with a high body mass index (BMI) may also have increased chest wall depth, which can result in failure of needle decompression if the anterior chest wall location is used.13 To contradict this, it is recommended to use the fifth intercostal space, along the anterior axillary line to reduce the risk of failed needle decompression.13

Longer needles can also be used for the second intercostal space but increase the risk of injury to the visceral structures.13

Chest Tubes 

Chest tubes are used to drain air or fluid or to deliver pleurodesis agents and empyema treatment.13 They are made up of silicone or polyvinyl chloride and are extremely flexible.13 They are sized based on their diameter and are available in multiple french (Fr) sizes, such as pigtail (< 14Fr), largest-bore catheters (40Fr), etc.; 1 Fr = ⅓ mm.13

Pigtail catheters are placed by using a finder needle and Seldinger technique.13 Large-bore chest tubes typically require larger incisions and direct entry of the doctor into the pleural space.13 Large-bore chest tubes are generally preferred for traumatic pneumothorax.13 However, small-sized chest tubes are also effective and result in less pain, and shorter hospital stays.13

Iatrogenic Pneumothorax

Initial management involves checking if the patient is stable or unstable and providing supplemental oxygen to maintain adequate oxygenation.11 Patients with a small  pneumothorax may require no treatment or intervention, and the trapped air can be observed with serial chest x-rays until the lung re-expands.11

The following are the treatment options available for iatrogenic pneumothorax:11

Table 1: Iatrogenic pneumothorax treatment/management11

TreatmentCharacteristics
Needle aspirationIs the first line treatment if the patient is unstable and is used to remove the excess air in the pleural space. A large-bore needle is temporarily placed on the second intercostal space in the midclavicular line. A finger thoracostomy is also used in which an incision is made over the lateral chest wall in the “safe triangle”  formed by the lateral border of the pectoralis major, the lateral border of the latissimus dorsi, the fifth intercostal space, and the base of the axilla. Next, a finger is inserted in the fifth intercostal space and dissects the pleural space. Thoracostomy uses negative pressure to seal and suction and reduce the trapped air in the pleural space.
Chest tube drainageChest tubes are inserted in the midclavicular line’s second or third intercostal space. They can also be inserted in the fourth or fifth intercostal space, also known as the Bulau position, anterior to the mid-axillary line.
Video-assisted thoracic surgery (VATS)Surgical and reserved for severe cases
Open surgical interventionSurgical and reserved for severe cases

Primary Spontaneous Pneumothorax (PSP)

The goal of PSP treatment is to reduce and remove air from the pleural space and prevent recurrences.6 There are multiple treatment options available, and consideration between them depends on the symptoms, the pneumothorax size, and the presence or absence of air leak.6 Treatment options include:6

Aspiration With a Catheter

Patients who are symptomatic and hemodynamically stable, or have a large-sized pneumothorax, around 2–3 centimeters of air in chest X-ray or more than 15% of the hemithorax, should undergo catheter aspiration.6 Aspiration can be done by inserting a chest tube until the lungs are re-expanded or inserting a catheter in the second intercostal space in the midclavicular line.6 Once the procedure is successful, the patient is discharged and followed up for 2 to 4 weeks.6

Chest Tube

A chest tube is also used to treat PSP by using a catheter attached to a one-way Heimlich valve and leaving it in place for one or more days.6 If the Heimlich valve fails, a water-seal device can also be used.6 70% of the air leaks are resolved within 7 days and 100% within 15 days.6 If air leaks persist for 7 days, surgical intervention should be considered.6

Pleurodesis

To reduce recurrence and persistent air leaks for more than 4 days, surgical pleurodesis via thoracoscopy is recommended by the American College of Chest Physicians.6 Methods include:6

  • Mechanical abrasion with gauze or Marlex
  • Pleural irritation with laser or cautery
  • Talc instillation
  • Tetracycline instillation

Video-Assisted Thoracoscopic Surgery (VATS)

Video-assisted thoracoscopic surgery (VTAS)  is a minimally invasive medical procedure to remove parts of the diseased lung and lymph nodes. During a VATS, a small tube with a camera called a thoracoscope is inserted through a small incision between the ribs, allowing the surgeon to see the entire chest cavity without having to open the chest or spread the rib. This type of procedure has lower morbidity rates in comparison to open thoracotomy.6

Thoracotomy

Thoracotomy used to be the primary surgical treatment option for PSP and involved an incision in the pleural space of the chest wall.6 It is indicated for recurrent PSP with persistent air leaks or collapsed lung after pleural drainage placement, and is superior to other surgical interventions because it allows for extensive mechanical pleurodesis and the resection of blebs.6 After surgical treatment, patients are at high risk of recurrence, especially in the first 30 days; thus, appropriate preventive measures should be taken.6

Secondary Spontaneous Pneumothorax

Secondary spontaneous pneumothorax is more severe than primary spontaneous pneumothorax and is associated with persistent air leaks and increased inpatient mortality and recurrence risk.7 Thus, there are multiple treatment options available, divided into initial management, management with persistent air leaks, and surgical interventions.7

Table 2: SSP management interventions7

TreatmentCharacteristics
                                                  Initial Management
Needle aspirationA small-bore cannula is inserted into the chest, and the air is aspirated with a syringe. The cannula is removed once all the air is aspirated. A 14 to16-gauge needle is used for the procedure. Admission for observation if the SSP is 1–2 cm at the hilum.
Ambulatory managementInvolves inserting a chest tube with a one-way flutter valve at the external end. Purpose-designed devices or the end  of a conventional chest tube can be used for attachment. Reduces hospital stay lengths but has a higher risk of serious adverse effects.
Persistent Air Leaks (PALs) Management Options
Persistent with CTDPALs are common in SSP and less likely to resolve. Studies suggest that in 61% of SSPs patients, PALs resolve at seven days, and 81% will resolve by 14 days without further intervention.
SuctionInvolves applying negative pressure to the drainage system. It accelerates air removal and promotes air leak closure by opposing the visceral and parietal pleura.
Chemical pleurodesisThe inflammation and fusion of the visceral and parietal pleurae are promoted by instilling an agent down the chest tube. The lungs must be fully inflated for the pleurae to be in apposition.
Autologous blood patch (ABP)Involves the instillation of small volumes (50–120 mL) of autologous blood into the pleural space through a chest drain to form a clot over the broncho-pleural fistula. ABP helps accelerate the healing of a PAL and provoke a pleurodesis reaction. It is associated with increased infection risk but can be resolved with conservative management.
Endobronchial/intrabronchial valvesThe valves are placed during a procedure with a flexible bronchoscope. They are positioned in lobar, segmental, or subsegmental bronchi and create a one-way valve, allowing the air to move out of the lung. Endobronchial/intrabronchial valves stop an air leak and allow the defective area of the lung to heal. It is less invasive than surgery but increases pleural infection risk and the need for more extensive surgical procedures if treatment is delayed.
Surgical management for PALPossible treatment methods include thoracoscopy, VATS, open thoracotomy, or a pleurodesis procedure. Surgical management of SSP is associated with a 5% mortality rate.

Catamenial Pneumothorax

There are no specific guidelines available for catamenial pneumothorax treatment.9 Surgery or hormonal therapies are used in combination or separately, depending on the cause of the pneumothorax, the patient’s overall health, age, and preference.9

Surgery is the gold standard for catamenial pneumothorax treatment due to fewer recurrence rates.10 For instance, video assisted thoracoscopic surgery is preferred because it is minimally invasive and allows for complete diaphragm visualization.10 Pleurodesis, which involves the artificial destruction of the pleural space, is also used for catamenial pneumothorax treatment.9 Pleural abrasion is also considered, which causes inflammation and adhesion of the pleurae by wearing down or rubbing away (abrading) the pleurae.9

Surgical options are recommended during menstruation as the endometriotic lesions are better visualized during the menstrual period.10

Hormonal therapy plays a supplemental role in treating catamenial pneumothorax and prevents recurrence.10 Gonadotropin-releasing hormone agonists are drugs that prevent menses and are commonly used to treat women with endometriosis.9 These drugs are suggested for all patients in the early postoperative period, around 6 to 12 months,  and have proven effective in treating catamenial pneumothorax.9,10

Tension Pneumothorax

Treatment of tension pneumothorax depends on the circumstances at the time of symptom onset and the hemodynamic stability of the patient.14 For instance, initial management involves:14

  • Assessing the chest trauma, airway, breathing, and circulation.
  • Using airtight occlusive bandages and clean plastic sheets for penetrating chest wounds.
  • Administering supplemental oxygen to reduce the pneumothorax size.
  • Placing a chest tube.

If the patient is hemodynamically unstable and has a high risk of tension pneumothorax, needle decompression, followed by tube thoracostomy, is performed.12,14 A large-bore needle (14 to 16 gauge) is placed at the second intercostal space in the midclavicular line above the rib with an angio-catheter.12,14 This causes the air rapped to release and the collapsed lungs to re-expand.12,14 Re-expanding increases the risk of pulmonary edema; thus, a CXR is performed, and a chest tube is placed.14 If a chest tube is insufficient, surgical options such as VATS or thoracotomy are considered.14

Chest Tube Considerations

What Does Chest Tube Care Involve Once it is Placed?

Multiple complications are associated with chest tubes, such as improper placement, infection, and pain during insertion, and can lead to life-threatening iatrogenic injuries if not managed properly.15 Thus, a trained healthcare provider is required to care for patients with chest tubes and an integrated care pathway combined with evidence-based medicine to plan to improve patient outcomes.15

The following are a few guidelines of care once a chest tube is placed:15,16

  • The chest tube should be secured to the chest wall using sutures, tape, or any manufactured appliance.
  • After insertion, the patient may lose a large amount of blood or transudate, resulting in hypotension. The healthcare professional must ensure that emergency airway equipment, patent vascular access, and the appropriate medications are available.
  • Prevent site infections through regular dressing changes.
  • Elevate the tube placement and suction level if you suspect subcutaneous emphysema.
  • Keep all tubing free of kinks and occlusions; check for tubing beneath the patient or pinched between bed rails.
  • Periodically add water to the water-seal and suction-control chambers to maintain adequate levels.
  • If bubbling in the water-seal chamber is continuous, suspect a leak in the system.
  • Avoid clamping a chest tube as it increases the risk of pneumothorax and prevents the trapped air from escaping.
  • If a chest tube is disconnected and contaminated, submerge the tube 1″ to 2″ (2 to 4 cm) below the surface of a 250-mL bottle of sterile water or saline solution until a new chest drainage unit (CDU) is set up.
  • In case of visible clots, squeeze hand-over-hand along the tubing and release the tubing between squeezes to help move the clots into the CDU.

How is the Chest Tube monitored?

The daily chest tube monitoring guidelines vary from institution to institution but generally includes:15,16

  • Evaluation of the fluid collected and its volume.
  • Assessment of the chest tube, the connective tubing, and the collection chamber.
  • Evaluation of the bilateral chest wall auscultation.
  • Daily chest x-rays or bedside ultrasounds to evaluate the risk of pneumothorax and concern about continued chest tube placement.
  • Radiographic evidence of the continued presence or resolution of the space-occupying lesion and the location of the sentinel port within the chest should be checked.
  • Document a comprehensive pulmonary assessment, including respiratory rate, work of breathing, breath sounds, and arterial oxyhemoglobin saturation measured by pulse oximetry (SpO2) every 2 hours.
  • If tidaling, fluctuations in the water-seal chamber with respiratory effort, do not occur, then the tubing is kinked, clamped, or filled with fluid.
  • Monitor the color and the amount of drainage in the collection chamber.

Signs That the Chest Tube is not Functioning

Multiple complications are associated with chest tube placement, positioning, and removal. These complications can lead to nonfunction of the chest tube from disturbed negative pressure within the chest drainage unit.17 Many factors lead to chest tube dysfunction by impairing the negative pressure in the CDU. An observation study examined 727 patients in which chest tube placement was performed for postoperative chest drainage, hydropneumothorax, pleural effusion, hemothorax, flail chest, tension pneumothorax, spontaneous pneumothorax, empyema thoracic, and chylothorax, and the following factors were found to be most commonly responsible for chest tube dysfunction:17

Table 3: Relative Frequency of Different Causes in Patients17

CausesFrequencyPercentage
Wrong Connections2417.3%
Odd Underwater Seal1913.7%
Inadequate Prime Fluid1510.8%
Loose Connections1510.8%
Overfull Bottles128.6%
Kinked Tubes107.2%
Clamping75.0%
Holes in Tubes75.0%
Sealed off Vent75.0%
Faulty Suction53.6%
Eyelet out of Pleural Space53.6%
Bottle Above Level of Chest53.6%
Absent Drainage Bottle21.4%

The following complications can occur as a result of  the above-mentioned factors:17,18

  • A blocked chest tube results in the failure of the fluid within the tube to fluctuate with coughing or respiration; this results in the undrained or unresolved pleural collection.
  • A faulty suction system inhibits lung re-expansion and drainage of the pleural space collection.
  • A kinked or angulated tube results in poor drainage capabilities.
  • Faulty connections and improper underwater seal problems can lead to pneumothorax recurrence.
  • Other complications and signs include subcutaneous placement, bleeding, laceration, perforation, or infection of other organs.

Interventions to Take When a Chest Tube is not Functioning

If a pneumothorax is not treated with a chest tube alone, surgical options are considered.19 Surgical options include a thoracotomy and VATS.19 A thoracotomy is considered for penetrating trauma cases, with or without vital signs, and on the patient’s selection criteria.19

A thoracotomy involves making an incision in the chest wall to access the contents of the thoracic cavity.20 There are two types of thoracotomies; anterolateral thoracotomies and posterolateral thoracotomies, which are subdivided into supra-mammary and infra-mammary and further divided into the right or left chest.20 Complications include bleeding, pleural effusion, pneumothorax, infection, shoulder dysfunction, and post-thoracotomy pain syndrome.20

Recently, VATS has been found to be more effective than thoracotomy for select patients with hemodynamically stable conditions for persistent non-massive hemothorax, persistent air leak, and diaphragmatic rupture.19 VATS is a minimally invasive surgery as compared to traditional surgery and involves smaller cuts and a special camera, called a thoracoscope, for diagnosing and treating various chest conditions.21 The procedure can be used to drain the lungs, remove a part of the organ, remove tissue, etc.21 Complications include infection, air leak, partially collapsed lung, excess bleeding, and pneumonia.21

Conclusion

Pneumothorax often begins as a benign condition but can quickly evolve into a severe medical condition if treatment and management are not followed.1 It also has a high recurrence rate; for instance, the recurrence rate in the first five years for primary spontaneous pneumothorax is 30%, and 43% for secondary spontaneous pneumothorax.1 Patients should be educated on the complications and preventive measures regarding pneumothorax. For instance, patients should quit smoking and avoid traveling by air or to remote areas until the pneumothorax is resolved.1

Patients should also avoid flying or scuba diving for a minimum of 2 weeks after their pneumothorax is resolved.1 If the pneumothorax is persistent or recurrent, VATS should be considered.1,  It reduces the recurrence rate of pneumothorax to less than 5%  within the first 3 years of the procedure.3 However, a smaller pneumothorax may not require treatment, while a larger pneumothorax may require management with conservative therapies, needle decompression, or chest tube drainage to resolve the evacuation.2

References
  1. McKnight CL, Burns B. Pneumothorax. PubMed. Published 2022. Accessed February 13, 2023. https://www.ncbi.nlm.nih.gov/books/NBK441885/#:~:text=Pneumothoraces%20can%20be%20even%20further
  2. Pneumothorax. www.hopkinsmedicine.org. https://www.hopkinsmedicine.org/health/conditions-and-diseases/pneumothorax
  3. Pneumothorax – Pulmonary Disorders. MSD Manual Professional Edition. Accessed February 13, 2023. https://www.msdmanuals.com/professional/pulmonary-disorders/mediastinal-and-pleural-disorders/pneumothorax#v4755987
  4. Imran JB, Eastman AL. Pneumothorax. JAMA. 2017;318(10):974. doi:https://doi.org/10.1001/jama.2017.10476
  5. Pneumothorax (Traumatic) – Injuries; Poisoning. MSD Manual Professional Edition. Accessed February 13, 2023. https://www.msdmanuals.com/professional/injuries-poisoning/thoracic-trauma/pneumothorax-traumatic#:~:text=Traumatic%20pneumothorax%20is%20air%20in
  6. Vallejo FAG, Romero R, Mejia M, Quijano E. Primary Spontaneous Pneumothorax, a Clinical Challenge. IntechOpen; 2019. https://www.intechopen.com/chapters/65152
  7. Nava GW, Walker SP. Management of the Secondary Spontaneous Pneumothorax: Current Guidance, Controversies, and Recent Advances. Journal of Clinical Medicine. 2022;11(5):1173. doi:https://doi.org/10.3390/jcm11051173
  8. Costumbrado J, Ghassemzadeh S. Pneumothorax, Spontaneous. PubMed. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK459302/
  9. Catamenial Pneumothorax – National Organization for Rare Disorders. rarediseases.org. Accessed February 13, 2023. https://rarediseases.org/rare-diseases/catamenial-pneumothorax/?filter=Standard+Therapies
  10. Amer K. Pneumothorax. IntechOpen; 2019.
  11. Ojeda Rodriguez JA, Hipskind JE. Iatrogenic Pneumothorax. PubMed. Published 2022. https://www.ncbi.nlm.nih.gov/books/NBK526057/#:~:text=Iatrogenic%20pneumothorax%20is%20a%20patient%20safety%20indicator%20(PSI)%20condition.
  12. Pneumothorax (Tension) – Injuries; Poisoning. MSD Manual Professional Edition. https://www.msdmanuals.com/professional/injuries-poisoning/thoracic-trauma/pneumothorax-tension
  13. Tran J, Haussner W, Shah K. Traumatic Pneumothorax: A Review of Current Diagnostic Practices And Evolving Management. The Journal of Emergency Medicine. 2021;61(5):517-528. doi:https://doi.org/10.1016/j.jemermed.2021.07.006
  14. PMC E. Europe PMC. europepmc.org. https://europepmc.org/article/nbk/nbk559090
  15. Merkle A, Cindass R. Care Of A Chest Tube. PubMed. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK556088/
  16. Bauman M, Handley C. Chest Tube Care: The More You Know, the Easier It Gets. https://www.myamericannurse.com/pdf/chest-tube-care-management-troubleshooting.pdf
  17. Hashmi U, Nadeem M, Aleem A, et al. Dysfunctional Closed Chest Drainage – Common Causative Factors and Recommendations for Prevention. Cureus. 10(3). doi:https://doi.org/10.7759/cureus.2295
  18. Kesieme EB, Dongo A, Ezemba N, Irekpita E, Jebbin N, Kesieme C. Tube Thoracostomy: Complications and Its Management. Pulmonary Medicine. Published 2012. https://www.hindawi.com/journals/pm/2012/256878/
  19. Bertoglio P, Guerrera F, Viti A, et al. Chest drain and thoracotomy for chest trauma. Journal of Thoracic Disease. 2019;11(Suppl 2):S186-S191. doi:https://doi.org/10.21037/jtd.2019.01.53
  20. Chang B, Tucker WD, Burns B. Thoracotomy. PubMed. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK557600/
  21. Video-Assisted Thorascopic Surgery. www.hopkinsmedicine.org. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/video-assisted-thorascopic-surgery
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