Tube Thoracostomy

Review Box 10-1 Tube thoracostomy: indications, contraindications, complications, and equipment.

Tube thoracostomy is a procedure used to evacuate an abnormal accumulation of fluid or air from the pleural space and can be performed on an elective, urgent, or emergency basis. Air or fluid can accumulate in the pleural space as a result of spontaneous or traumatic pneumothorax, pleural fluid accumulation of blood, malignancy, infection (empyema), or lymph (chylothorax). The first modern methods to evacuate the contents of the pleural space were developed in the 19th century, but these techniques did not become widespread until 1918, when they were used to treat postinfluenza empyema. Military experience demonstrated that thoracic drainage combined with antiseptics and antibiotics reduced mortality related to thoracic trauma from 62.5% during the Civil War, to 24.6% in World War I, and to 12% in World War II.¹

Pathophysiology

The lung is surrounded by two layers, the parietal pleura, which lines the interior of the chest wall, and the visceral pleura, which covers the lungs. They are separated by a thin layer of lubricating fluid within the “pleural space.” A small negative pressure within the pleural space helps keep the lung inflated and the two layers closely apposed. With inspiration, the negative intrathoracic pressure increases and leads to expansion of the lung from an influx of air. If the pleural space is disrupted, air, blood, or other fluid can accumulate in between the two layers of the pleura and the normal pressure gradient is compromised. This interferes with normal inspiratory-induced inflation and leads to “collapse” of the lung. As the amount of fluid or air increases, respiratory function worsens and symptoms of dyspnea are produced, often with pleuritic chest pain and anxiety. The degree of respiratory compromise depends on the volume of fluid or air in the pleural space, the patient’s age, baseline pulmonary status, and the integrity of the chest wall. The positive pressure accumulation of air associated with tension pneumothorax leads to severe respiratory dysfunction and cardiovascular compromise.

A pneumothorax is caused by the presence of air in the pleural space and the loss of negative pressure (Fig. 10-1). Air can enter the pleural space from the outside as a result of a penetrating injury or internally from a ruptured lung bleb or damaged trachea. Iatrogenic causes from needle procedures such as subclavian venous cannulation, transthoracic biopsy, thoracentesis, positive pressure ventilation (PPV), or cardiopulmonary resuscitation (CPR) are also common (Fig. 10-2). Pneumothoraces are commonly divided into “open” and “closed.” An open pneumothorax indicates that the skin and underlying soft tissue sustained an injury that penetrated into at least the pleural space.

Figure 10-1 Pneumothorax. A, Anteroposterior chest radiograph of a right-sided, seemingly small, simple pneumothorax (PTX). Note the absence of peripheral lung markings on the right side and the distinct line indicating the edge of the collapsed lung (arrow). Although this appears to be a small PTX, it produced significant dyspnea in this patient with chronic obstructive pulmonary disease and therefore required a chest tube. B, Computed tomography scan showing the extent of the collapse. Adhesions kept part of the lung expanded.

Figure 10-2 A, After successful cardiopulmonary resuscitation and intubation, this patient began to deteriorate, with a precipitous drop in blood pressure and decreasing oxygen saturation. It was believed that the cause of the initial cardiac arrest was returning. Marked subcutaneous air was noted in the scrotum and abdominal wall, but little air was noted in the chest wall tissue. The subcutaneous air had curiously tracked via tissue planes, a distinctly unusual place for air to accumulate. B, A chest tube (arrow) quickly reversed the decompensation. C, This patient suffered respiratory arrest from heroin injected into a neck vein (note the extensive scar). After bag-mask resuscitation the respiratory depression returned, he was unresponsive to naloxone, and he was very difficult to ventilate. He had a small pneumothorax (PTX) from a nick in the lung from the neck injection.

Spontaneous (Closed) Pneumothorax

Spontaneous pneumothorax is caused by rupture of a subpleural lung bleb with little or no trauma and can be categorized as either primary or secondary based on the presence of underlying lung disease. Primary spontaneous pneumothorax occurs in a patient without overt lung disease. The typical patient with spontaneous pneumothorax is a tall, thin, 20- to 40-year-old male smoker (Fig. 10-3). Secondary spontaneous pneumothoraces occur in patients with underlying lung or pleural disease, including emphysema, chronic bronchitis, asthma, Marfan’s syndrome, infection, and neoplasm. The morbidity, mortality, and long-term complications associated with pneumothorax increase in patients with underlying lung disease. Whereas a primary pneumothorax may be selectively observed or simply aspirated, a secondary pneumothorax often requires a more aggressive approach to management.

Figure 10-3 Spontaneous pneumothorax. A, Spontaneous pneumothorax in a young male patient. There is nearly total collapse of the right lung, and lung markings are absent lateral to the visible pleural reflection (arrow). Note also the slight deviation of the mediastinum to the contralateral side. B, The patient was treated with a pigtail catheter inserted in the second intercostal space in the midclavicular line (arrow). Note that the lung has totally reexpanded and the mediastinum has shifted back to the midline.

The sudden onset of pleuritic chest pain and dyspnea with exertion or at rest is the most common finding. More subtle manifestations occur with little or no pain and only mild dyspnea on excursion that the patient may ignore for days. A person with a small spontaneous pneumothorax may never seek medical attention, and the process will resolve without treatment. The signs and symptoms do not always correlate well with the size or cause of the collapsed lung. Tube thoracostomy is the most common treatment, but new trials suggest that conservative management or aspiration of first-time primary pneumothoraces results in similar outcomes as traditional tube thoracostomy, though with fewer complications, shorter hospital stay, and lower cost. Conservative management and aspiration are both reasonable initial interventions in clinically stable patients. However, to date no high-quality clinical trials have definitely demonstrated that aspiration is a superior treatment methodology.2–4 Rarely, a spontaneous pneumothorax may be bilateral or progress to tension pneumothorax, a potentially life-threatening condition that is described in more detail later in this chapter.

Traumatic Closed Pneumothorax

A closed pneumothorax may also result from an injury without penetration of the chest wall, usually from a rib fracture that penetrates the lung, but also when an alveolus or bleb ruptures after blunt trauma. The air leak from a closed pneumothorax is generally self-limited but can rarely progress to a tension pneumothorax.

Traumatic Open Pneumothorax

An open pneumothorax occurs when the chest wall is penetrated and the negative intrapleural pressure is lost. Each breath can increase intrapleural pressure. If the diameter of the chest wound is greater than the diameter of the trachea, with each respiratory attempt, air moves preferentially through the chest wall opening rather than down the trachea and thus prevents meaningful ventilation of the involved lung.

Tension Pneumothorax

An open pneumothorax can occasionally be manifested as a tension pneumothorax, which is a life-threatening condition that requires immediate intervention. A tension pneumothorax occurs when an injury creates a one-way “flap valve” mechanism that allows air into the pleural space with inspiration but then closes with expiration and traps the air (Fig. 10-4). The progressive accumulation of air in the pleural space leads to ipsilateral complete lung collapse and then impingement on the mediastinum with a shift of the heart toward the uninvolved side, which restricts ventricular filling and subsequently decreases cardiac function. This severe disruption in both respiratory and cardiac function can lead to hypotension and reduced ventilation (both hypoxia and CO₂ retention) and eventually to cardiopulmonary collapse.

Figure 10-4 Traumatic tension pneumothorax. A and B, Pathophysiology of a tension pneumothorax. During inspiration, air enters the pleural space through a one-way valve either from the outside or from the lung itself. On expiration, the injury/valve closes and traps increasing amounts of air in the pleural space. Eventually, the mediastinum shifts and cardiac filling and ultimately cardiac output are compromised. C, This elderly patient sustained a tension hemopneumothorax after slipping and falling on ice. The left hemithorax is very dark (radiolucent) because of total collapse of the left lung (large white arrow). Note the dramatic shift of the mediastinum to the right, indicative of tension. Multiple posterior rib fractures are present but are difficult to appreciate on this film (small white arrows). The air-fluid level (black arrow) indicates the presence of fluid in the pleural cavity in addition to air. D, A computed tomography scan of the same patient redemonstrates the findings seen on the conventional radiograph.

A tension pneumothorax is usually caused by penetrating chest injuries but can result from fracture of the trachea or bronchi, a ruptured esophagus, the presence of an occlusive dressing over an open pneumothorax, and PPV. Patients with chest or lung injuries who are treated with PPV are at much greater risk for the development of a tension pneumothorax. Consequently, any patient with a penetrating thoracic injury (even without immediate evidence of a hemothorax or pneumothorax) may be a candidate for a “prophylactic” chest tube before mechanical ventilation. A pneumothorax may also develop in patients with asthma or emphysema from the high pressure required for ventilation, followed by a tension pneumothorax.

Hemothorax

Hemothorax is an accumulation of blood in the pleural space as a result of injury to the heart, great vessels, or vessels of the lungs, mediastinum, or chest wall. Bleeding from the lung parenchyma is low pressure and usually self-limited or ceases when a chest tube is inserted. On the other hand, bleeding from an intercostal artery, a pulmonary artery, or the internal mammary artery can be profuse and often requires surgical intervention.

Empyema and Effusions

An empyema is an accumulation of pus in the pleural space, usually from a parapneumonic infectious effusion (Fig. 10-5). An empyema can also be caused by violation of the thoracic space by surgical procedures (e.g., tube thoracostomy), trauma, and esophageal perforation. Pleural infection rates have increased 3% per year in the United States in the last 2 decades. The bacteriology of pleural infections appears to track closely with classification of pneumonia as community or hospital acquired. Nearly 60% of cases of community-acquired pneumonia are caused by Streptococcus pneumoniae species, whereas Staphylococcus species account for nearly 45% of hospital-acquired infections.⁵

Figure 10-5 Empyema. This 34-year old patient with a history of alcoholism had fever, cough, pleuritic chest pain, and hypoxia. A, Posteroanterior chest radiograph demonstrating nearly total opacification of the right hemithorax. The presence of a meniscus (large arrow) suggests a pleural effusion. However, small lucent areas (small arrows) can be seen throughout the opacity, which may represent air bronchograms in consolidated lung parenchyma. Thus, a computed tomography (CT) scan was performed. B, CT revealed nearly total collapse of the right lung with only a small portion of the apex remaining inflated (white arrow). A massive pleural collection was found with gas bubbles throughout (black arrows), suggestive of pyogenic empyema. Tube thoracostomy was performed and more than 1700 mL of purulent fluid was drained. Fluid cultures grew Streptococcus anginosus.

Chylothorax

Chylothorax results from injury to the thoracic duct during placement of a central line, operative injury, or chest trauma. Primary thoracic duct injury is usually asymptomatic because the chyle initially collects extrapleurally and may not begin to fill the pleural cavity for 2 to 10 days. As the fluid accumulates, respiratory symptoms slowly develop. The chest radiograph demonstrates a pleural effusion, and the diagnosis is made when thoracentesis reveals a milky fluid with a high fat and lymphocyte content and 4 to 5 g/dL of protein. Definitive treatment is either repeated thoracentesis or tube thoracostomy combined with parenteral alimentation until the volume of chyle decreases.

Diagnosis

Symptoms

The symptoms of patients with abnormal collections in the pleural space range widely depending on the size of the pneumothorax, the rapidity of accumulation, the age of the patient, and the presence of an underlying lung disease. Specific symptoms range from mild dyspnea with exercise and pleuritic chest pain with small disruptions to hypotension or severe dyspnea in those with tension pneumothorax. With a spontaneous pneumothorax, 95% of patients complain of the sudden onset of sharp, pleuritic chest pain, shoulder pain, or both. Sixty percent of patients experience dyspnea, and 12% have a mild cough. Dyspnea and anxiety are more common in older patients.

Tension pneumothorax must be considered in any patient with sudden respiratory or cardiac deterioration and in intubated patients who become difficult to ventilate because of increased airway pressure, hypotension, or elevated central venous and pulmonary artery pressure. Severe dyspnea, restlessness, agitation, and a feeling of impending doom will develop rapidly in conscious patients with tension pneumothorax. They are usually tachycardic and tachypneic and can quickly become hypotensive.

The symptoms of hemothorax can be similar to those of pneumothorax but may be accompanied by hypotension as blood accumulates in the pleural space. The onset of symptoms with effusions is usually much more gradual, with increasing shortness of breath and dyspnea on exertion occurring over a period of days to weeks.

Physical Examination

Unstable Patients

During the initial phase of resuscitation (airway, breathing, circulation, disability), consider the diagnosis of pneumothorax in patients who are tachycardic, hypotensive, and dyspneic. Similar symptoms occur with pulmonary embolism, pericardial tamponade, and severe pneumonia. Conduct multiple examinations because the diagnosis of tension pneumothorax by physical examination can be very subtle. Use the phrase “look, listen, and feel” as your guideline. Observe the chest wall, which may reveal asymmetric chest expansion, and the neck and forehead veins, which may be distended, even if the patient is hypotensive. The trachea may be deviated away from the side of the pneumothorax. When percussing the chest wall, hyperresonance on the affected side and subcutaneous emphysema may be present. Auscultation may demonstrate diminished breath sounds on the injured side. In one prospective study, the sensitivity, specificity, and diagnostic accuracy of auscultation for hemothorax and pneumothorax were 84%, 97%, and 89%, respectively.⁶ A false-negative auscultation is more likely than a false-positive one.⁶ Pulsus paradoxus may be evident. For intubated patients, an early sign of tension pneumothorax is difficulty ventilating because of increased airway pressure.

In injured patients with apnea, hypotension, or cardiopulmonary arrest, diagnose and treat a tension pneumothorax by immediate needle or catheter decompression thoracentesis; do not take the time taken to obtain and review a radiograph because delay can lead to increased morbidity and mortality in patients with this emergency condition. Confirm the diagnosis of tension pneumothorax by observing rapid improvement in vital signs and a rush of air through the needle.

Stable Patients

In more stable patients (and those with smaller accumulations) the findings on physical examination are less sensitive, and a chest radiograph or even a computed tomography (CT) scan is usually necessary to make a definitive diagnosis. Physical findings may include unilaterally decreased breath sounds, tachypnea, tachycardia, decreased tactile fremitus, increased resonance with percussion, or subcutaneous emphysema, but the examination may reveal little to no abnormalities with a small pneumothorax. Patients with a pneumothorax involving less than 20% of the hemithorax will often have completely normal findings on chest examination, including equal breath sounds (Fig. 10-6). Pleural fluid collections are difficult to detect by physical examination, particularly with less than 500 mL of fluid in the pleural space. Breath sounds may be decreased and percussion of the bases may be dull.

Figure 10-6 Smaller pneumothoraces such as this (note the faintly visible pleural reflection [arrow], absence of lung markings at the left apex, and relative crowding of vessels at the left hilum) can be difficult to see on radiographs and even harder—if not impossible—to appreciate on physical examination. Patients with a pneumothorax of less than 20% will often have completely normal findings on chest examination, including equal breath sounds.

Parapneumonic empyemas are often accompanied by fever, cough, chest pain, dyspnea, and purulent sputum (see Fig. 10-5). Physical examination may reveal diminished breath sounds, dullness on percussion, egophony, and diminished tactile fremitus on the involved side. Fever will often develop in patients with an indwelling chest tube and empyema. The pleural fluid drainage may be copious and purulent, and respiratory symptoms may worsen.

Radiography

Plain Radiographs

A chest radiograph is an essential tool for diagnosing a pneumothorax in stable patients. In unstable patients with a potential tension pneumothorax the diagnosis should be made clinically, but in rare cases a portable radiograph may be obtained in the resuscitation room if carefully monitored by a clinician. The best plain radiographs for hemothorax or pneumothorax are traditional upright inspiratory posteroanterior and lateral chest radiographs. Diagnostic sensitivity is not increased with an expiratory upright chest radiograph. Upright is preferable to a supine chest radiograph, particularly for a hemothorax, because even with large amounts of blood there may only be slight differences in the density of the lung fields since the blood may layer out evenly. With an upright chest radiograph, 300 to 500 mL of fluid is needed to cause blunting of the costophrenic angle (Fig. 10-7).⁷ When CT is not available, other useful views include a bilateral decubitus chest radiograph, with the pneumothorax expected to be seen on the side away from the table as gravity pulls the affected lung down.

Figure 10-7 Hydropneumothorax. This radiograph is an excellent example of a hydropneumothorax. When accumulated fluid in the chest cavity is seen as a straight line on a radiograph (an air-fluid level [black arrow]) with no meniscus up the side, air must be present in the pleural space. In this patient the pneumothorax is readily visualized, with no lung markings seen lateral or superior to the pleural reflection (white arrows).

On a chest radiograph the partially collapsed lung of a pneumothorax appears as a visceral pleural line with no pulmonary markings beyond it (see Figs. 10-1, 10-3, 10-6, and 10-7). It is easy to initially mistake large blebs for a pneumothorax or to identify the scapular border, skin folds, or indwelling lines as a pneumothorax, but a CT scan quickly resolves the issue (Fig. 10-8). Other radiographic findings include hyperlucency of the affected hemithorax, a double diaphragm contour, increased visibility of the inferior cardiac border, better visualization of pericardial fat at the cardiac apex, and possibly a depressed diaphragm. If subcutaneous air is noted on the chest radiograph of a patient with blunt chest trauma, it can be assumed that the air came from an injured lung and that a pneumothorax exists.

Figure 10-8 Pneumothorax and bullous emphysema. This patient had a history of severe chronic obstructive pulmonary disease and arrived at the emergency department in respiratory distress. A, On the chest radiograph, both apices are relatively radiolucent, and faint lines can be seen coursing through that are not clearly blebs or pleural reflections (arrows). B, A computed tomography scan was obtained and defined the pathology in detail. In the right apex there is no pneumothorax, but rather large blebs are present (small white arrows). On the left a pleural reflection is clearly visible (large white arrow), indicative of pneumothorax. Subcutaneous air is also noted in the thoracic soft tissues (black arrows), thus further supporting the diagnosis of pneumothorax. (This finding is also evident on the chest radiography but was overlooked on the initial interpretation.)

It is difficult to accurately predict the size of a pneumothorax on plain radiographs. Greater accuracy in predicting size can be accomplished with a CT scan. With a tension pneumothorax, the chest radiograph reveals lung collapse, a depressed hemidiaphragm on the affected side, and a shift of the mediastinum and trachea to the opposite side (see Fig. 10-4). With a bilateral pneumothorax, no mediastinal shift may be seen.

Thoracic CT

The gold standard for diagnosis is a thoracic CT scan, which can detect a pneumothorax not easily visible on a plain radiograph. CT scans of the chest are much more sensitive than plain radiographs in detecting hemothorax and pneumothorax. They are also more accurate for estimating the size and other characteristics of a pneumothorax (see Figs. 10-1, 10-4, and 10-8). CT scans are not routine for diagnosis of a pneumothorax but are more useful for hemothoraces and other fluid collections. They also offer invaluable information on the cause of such abnormalities. A CT scan may be useful when the diagnosis is unclear or when looking for small amounts of pleural fluid. CT scans are particularly helpful in determining whether an empyema is loculated or draining successfully. About 10% of trauma patients with normal findings on a chest radiograph will demonstrate a small hemothorax or pneumothorax.^7–9 The clinical significance of a small, previously undetected occult injury is probably not great, and it has been suggested that a small pneumothorax seen only on CT may be left untreated and simply observed in otherwise stable patients. Some patients with a pneumothorax seen only on CT may also safely undergo PPV without placement of a chest tube.⁹

Ultrasound

Ultrasound is useful in diagnosing both hemothoraces and pneumothoraces, and its use is reviewed in the Ultrasound Box.10,11

Ultrasound

Recognizing Pneumothoraxby Christine Butts, MD

To evaluate for pneumothorax, a high-frequency transducer should be used to ensure a high degree of resolution. In a supine patient the transducer should be placed on the anterior chest wall in the midclavicular line at approximately the second to third intercostal space (Fig. 10-US1). The depth of the image should be adjusted until the ribs are seen as brightly echogenic (white) arcs with acoustic shadows behind them. The pleural line can be found just deep to the ribs and is represented as a horizontal, echogenic line (Fig. 10-US2). In a normal lung the visceral and parietal pleural layers are directly opposed to one another (save for a thin layer of pleural fluid). When the patient breathes in and out, the layers “slide” past each other to allow the lungs to expand. When this is viewed with ultrasound, the pleural line can be seen to slide back and forth with patient respiration. This is referred to as the “slide sign.” In cases in which this interface is disrupted (such as by a pneumothorax), the sliding is lost. When these patients are evaluated with ultrasound, the pleural line will be seen as a static echogenic line that does not change with respiration.

Figure 10-US1 Proper positioning of the probe for evaluation of pneumothorax.

Figure 10-US2 Ultrasound image of the pleura as seen with a high-frequency transducer. The pleura can be recognized as a hyperechoic (white) line (arrow) that normally moves back and forth with respiration. Identifying the rib, along with its accompanying shadow (arrowhead), often aids in identifying the pleura because it will lie immediately deep to the rib.

Although the slide sign carries significant sensitivity for ruling out a pneumothorax, other secondary confirmatory findings should be sought as well.¹

Comet tail artifacts may be seen in a normal lung. These are hyperechoic vertical lines that extend deep to the pleural interface (Fig. 10-US3). Typically, they will be seen in small numbers in a normal lung. Patients in whom a pneumothorax is present are noted to lack comet tails because this artifact arises from the normal pleural interface, which is disrupted. The presence of comet tails may be used by the sonographer to further rule out a pneumothorax.^2,3

Figure 10-US3 This image demonstrates two key artifacts seen in a normal lung. As with the previous image, the pleura is recognized as a hyperechoic horizontal line deep to the ribs (at the far right and left of the image). A comet tail, a small vertical line, can be seen extending deep to the pleura (arrow). This is a normal artifact created by the pleura, and its presence aids in ruling out a pneumothorax. A-lines, or a series of horizontal lines extending deep to the pleura, can also be seen (arrowhead). These artifacts may be seen both in normal lung and in the presence of pneumothorax.

M-mode may also be used to further evaluate for the presence of a pneumothorax. M-mode is used to evaluate objects in motion and plots a linear representation of motion on screen. Objects that move toward the surface (or toward the transducer) are represented by an upward deflection. Objects that move away from the transducer are represented by a downward deflection. Objects that are not in motion are represented by a solid line.

In a normal patient, the pleura will slide back and forth as the patient breathes. Because this motion is neither toward nor away from the transducer but instead is parallel, the motion will be seen as a series of hazy lines deep to the pleura. The overlying soft tissue is not in motion and will be seen as a series of clear, flat lines. This typical appearance is described as the “seashore” sign (Fig. 10-US4).

Figure 10-US4 Seashore sign seen in a normal lung. This M-mode image shows movement of the pleura. The solid lines at the top of the image represent the immobile skin, soft tissue, and muscle. The hazy lines at the bottom of the image represent the back-and-forth movement of the normal pleura.

In patients in whom a pneumothorax is present, no motion is detected by ultrasound. Therefore, the M-mode tracing will show clear, flat lines throughout the frame. This is referred to as the “stratosphere” or “bar code” sign (Fig. 10-US5).

Figure 10-US5 Bar code sign consistent with a pneumothorax. This M-mode image shows lack of movement of the pleura. Unlike the previous image, the solid lines can be seen to continue past the point of the pleural line. Because the presence of the pneumothorax causes the pleura to appear stationary, no movement is seen in this image.

References:

1. Blaivas, M, Lyon, M, Duggal, S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med. 2005;12:844–849.

2. Lichtenstein, D, Meziere, G, Biderman, P, et al. The comet-tail artifact: an ultrasound sign ruling out pneumothorax. Intensive Care Med. 1999;25:383–388.

3. Chan, SS. Emergency bedside ultrasound to detect pneumothorax. Acad Emerg Med. 2003;10:91–94.

Indications for Tube Thoracostomy

Pneumothorax

Tube thoracostomy is by far the most common treatment of all types of pneumothoraces, but controversy exists over the treatment of small traumatic and spontaneous primary pneumothoraces. However, the American College of Chest Physicians has developed useful guidelines for the management of primary and secondary spontaneous pneumothoraces (Box 10-1).¹²

Box 10-1

Guidelines of the American College of Chest Physicians for the Management of Primary and Secondary Spontaneous Pneumothoraces

Primary Spontaneous Pneumothorax (No Underlying Lung Disease)

A clinically stable patient must have all of the following present: respiratory rate lower than 24 breaths/min, heart rate higher than 60 beats/min or less than 120 beats/min, normal blood pressure, room-air O₂ saturation higher than 90%, and the ability to speak in whole sentences between breaths.

Clinically Stable Patients with Small Pneumothoraces (<3-Cm Apex-to-Cupola Distance)

Clinically stable patients with small pneumothoraces (PTXs) should be observed in the emergency department (ED) for 3 to 6 hours and be discharged home if a repeated chest radiograph excludes progression of the PTX (good consensus). Patients should be provided with careful instructions for follow-up within 12 hours to 2 days, depending on the circumstances. A chest radiograph should be obtained at the follow-up appointment to document resolution of the PTX. Patients may be admitted for observation if they live distant from emergency services or follow-up care is considered unreliable (good consensus). Simple aspiration of the PTX or insertion of a chest tube is not appropriate for most patients (good consensus) unless the PTX enlarges. The presence of symptoms for longer than 24 hours does not alter the treatment recommendations.

Only gold members can continue reading. Log In or Register to continue