When do you put in a chest tube for spontaneous pneumothorax?

Dr. Kristina Porada, PGY-1

Why do we care?

■Spontaneous pneumothoraces affect >20,000 patients per year in the U.S. and account for ~$130,000,000 in health care expenditures

■14.1 per 100,000 in population > 15 years old

–Males > females

■Most common cause of secondary spontaneous pneumothorax is COPD

■Most common early physical exam findings = tachycardia

What does the textbook say?

2 goals of management: evacuate air from the pleural space and prevent recurrence

American College of Chest Physicians Consensus Statement

Primary Spontaneous Pneumothorax


Secondary Spontaneous Pneumothorax

ACCP v.s. British Thoracic Society

Literature Review

NEJM: Conservative vs. interventional treatment of spontaneous pneumothorax (2020) 

■Conservative management is noninferior to interventional management for radiographic resolution of moderate-to-large primary spontaneous pneumothorax

–Spared 85% of patients from invasive intervention

–Fewer days in hospital or off from work

–Lower rates of surgery

–Lower risk of serious adverse events or pneumothorax recurrence


ERJ: Randomised comparison of needle aspiration and chest tube drainage in spontaneous pneumothorax (2017) 

■Duration of hospital stay after needle aspiration is almost half the length of that for chest tube drainage (primary and secondary spontaneous PTX)

■Complication rate is negligible for needle aspiration compared to chest tube drainage

■No significant difference in 1 year recurrence rates

■Significant advantage for needle aspiration over chest tube drainage for immediate successes for both primary and secondary spontaneous PTX


So...size matters

Where we see a shift

■Conservative management of stable, mildly symptomatic, LARGE primary spontaneous pneumothorax

–Can be considered for patients < 50 years old

–Monitor for 4 hours in the ED with repeat CXR

–Stable patient with normal vitals, can ambulate comfortably à DC with repeat CXR in 24 hours

–Any increase in size warrants intervention

One more thought

■Is there a role for POCUS in the diagnosis over supine chest radiography?

–A topic for a different place and time

–But spoiler alert: if that place is the trauma bay, then yes

Clinical Implications

Attending Questions

■Do you ever order CT chest to follow up on pneumothorax seen on CXR? If so, under what circumstances?

■Do you have absolute contraindications for observation in the ED and discharge home regardless of the size of pneumothorax and clinical appearance of patient?

■Does your approach to pneumothorax change at all in children (age < 15)?