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Ovid: Oxford Handbook of Respiratory Medicine

Authors: Chapman, Stephen; Robinson, Grace; Stradling, John; West, Sophie Title: Oxford Handbook of Respiratory Medicine, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Part 4 – Practical procedures > Chapter 65 – Aspiration of pneumothorax Chapter 65 Aspiration of pneumothorax P.680
Indications

  • Primary pneumothorax Consider aspiration if patient breathless and/or pneumothorax large (rim of air > 2 cm on CXR)
  • Secondary pneumothorax Consider aspiration if patient aged <50 years, with small pneumothorax (rim of air < 2 cm on CXR) and minimal breathlessness.

Technique Refer to pages 294–5 for treatment algorithms.

  • Discuss procedure with patient and obtain written consent (unless emergency situation).
  • Insert IV cannula.
  • Position patient sitting upright, supported on pillows.
  • Double-check correct side from chest examination and CXR.
  • Choose aspiration site: second intercostal space in midclavicular line on side of pneumothorax.
  • Infiltrate skin, intercostal muscle, and parietal pleura with 10 ml of 1% lidocaine. Aim just above the upper border of the appropriate rib, avoiding the neurovascular bundle that runs below each rib. Parietal pleura is extremely sensitive; use the full 10 ml of lidocaine.
  • Sterile skin preparation. Wear sterile gloves and gown.
  • Whilst waiting for anaesthetic to work, connect 50 ml syringe to 3 way tap, with tap turned ‘off’ to patient.
  • Confirm presence of pneumothorax by aspirating air with green (21G) needle.
  • Insert large-bore (e.g. 16G) cannula over upper border of rib. Remove inner needle, quickly connect cannula to three-way tap and 50 ml syringe.
  • Aspirate 50 ml air with syringe, turn tap and expel air into atmosphere. Repeat until resistance felt, or 2.5 litres of air aspirated (aspiration of > 2.5 litres suggests a large air-leak, and aspiration is likely to fail). Halt procedure if painful, or patient coughing excessively.
  • Remove cannula; cover insertion site with dressing.
  • Repeat CXR. Ideal timing of CXR following aspiration is unknown; it may be advisable to wait several hours before performing the CXR, in order to detect slow air leaks.
  • Aspiration is successful if lung is fully re-expanded on CXR.
  • If initial aspiration of a primary pneumothorax fails, repeat aspiration should be considered (unless ≥ 2.5 litres has already been aspirated). At least one-third of patients will respond to a second aspiration.

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