Outpatient Management of A Spontaneous Pneumothorax

by Joseph Esherick, M.D., FAAFP, FHM

A patient with a hemodynamically stable spontaneous pneumothorax can be managed as an outpatient using the placement of a small-bore pigtail catheter attached to a Heimlich valve.

 

As the Director of Medicine at a teaching hospital, I frequently encounter patients who have undergone traditional tube thoracostomy with the chest tube connected to a Pleur-Evac container for a simple, uncomplicated pneumothorax.  This is not only an unnecessary admission, but the patient often endures excessive discomfort during traditional chest tube placement and will be left with a much larger scar than is necessary.

 

All that is needed for an uncomplicated pneumothorax (even a large pneumothorax), is a small pigtail catheter and a Heimlich valve (e.g., a Wayne Pneumothorax Evacuation Kit).  Unlike traditional chest tube insertion, procedural sedation is usually not needed for pigtail catheter insertion.[1] 

 

The pigtail catheter can be inserted in the mid-clavicular line of the second intercostal space or in the mid-axillary line using a generous amount of local anesthesia.  The catheter is then connected to a Heimlich valve (Figure 1) and the patient can be sent out from the emergency department.  They are instructed to keep the Heimlich valve dry and to return daily for chest x-rays until the lung is fully inflated at which time the catheter is removed.

 
Pigtail catheter connected to Heimlich valve