The treatment of<unk>  depends on a number of factors and may vary from discharge with early follow-up to immediate needle decompression or insertion of a chest tube. Treatment is determined by the severity of symptoms and indicators of acute illness, the presence of underlying lung disease, the estimated size of the<unk>  on X-ray, and – in some instances – on the personal preference of the person involved. In traumatic<unk> , chest tubes are usually inserted. If mechanical ventilation is required, the risk of tension<unk>  is greatly increased and the insertion of a chest tube is mandatory. Any open chest wound should be covered with an airtight seal, as it carries a high risk of leading to tension<unk> . Ideally, a dressing called the "Asherman seal" should be utilized, as it appears to be more effective than a standard "three-sided" dressing. The Asherman seal is a specially designed device that adheres to the chest wall and, through a valve-like mechanism, allows air to escape but not to enter the chest. Tension<unk>  is usually treated with urgent needle decompression. This may be required before transport to the hospital, and can be performed by an emergency medical technician or other trained professional. The needle or cannula is left in place until a chest tube can be inserted. Critical care teams are able to incise the chest to create a larger conduit as performed when placing a chest drain, but without inserting the chest tube. This is called a simple thoracostomy. If tension<unk>  leads to cardiac arrest, needle decompression or simple thoracostomy is performed as part of resuscitation as it may restore cardiac output. Conservative Small spontaneous<unk> es do not always require treatment, as they are unlikely to proceed to respiratory failure or tension<unk> , and generally resolve spontaneously. This approach is most appropriate if the estimated size of the<unk>  is small (defined as 50%), or in a PSP associated with breathlessness, some guidelines recommend that reducing the size by aspiration is equally effective as the insertion of a chest tube. This involves the administration of local anesthetic and inserting a needle connected to a three-way tap; up to 2.5 liters of air (in adults) are removed. If there has been significant reduction in the size of the<unk>  on subsequent X-ray, the remainder of the treatment can be conservative. This approach has been shown to be effective in over 50% of cases. Compared to tube drainage, first-line aspiration in PSP reduces the number of people requiring hospital admission, without increasing the risk of complications. Aspiration may also be considered in secondary<unk>  of moderate size (air rim 1–2 cm) without breathlessness, with the difference that ongoing observation in hospital is required even after a successful procedure. American professional guidelines state that all large<unk> es – even those due to PSP – should be treated with a chest tube. Moderately sized iatrogenic traumatic<unk> es (due to medical procedures) may initially be treated with aspiration. Chest tube A chest tube placed on the right for a<unk>  A chest tube (or intercostal drain) is the most definitive initial treatment of a<unk> . These are typically inserted in an area under the axilla (armpit) called the "safe triangle", where damage to internal organs can be avoided; this is delineated by a horizontal line at the level of the nipple and two muscles of the chest wall (latissimus dorsi and pectoralis major). Local anesthetic is applied. Two types of tubes may be used. In spontaneous<unk> , small-bore (smaller than 14 F, 4.7 mm diameter) tubes may be inserted by the Seldinger technique, and larger tubes do not have an advantage. In traumatic<unk> , larger tubes (28 F, 9.3 mm) are used. When chest tubes are placed due to either blunt or penetrating trauma, antibiotics decrease the risks of infectious complications. Chest tubes are required in PSPs that have not responded to needle aspiration, in large SSPs (>50%), and in cases of tension<unk> . They are connected to a one-way valve system that allows air to escape, but not to re-enter, the chest. This may include a bottle with water that functions like a water seal, or a Heimlich valve. They are not normally connected to a negative pressure circuit, as this would result in rapid re-expansion of the lung and a risk of pulmonary edema ("re-expansion pulmonary edema"). The tube is left in place until no air is seen to escape from it for a period of time, and X-rays confirm re-expansion of the lung. If after 2–4 days there is still evidence of an air leak, various options are available. Negative pressure suction (at low pressures of –10 to –20 cmH2O) at a high flow rate may be attempted, particularly in PSP; it is thought that this may accelerate the healing of the leak. Failing this, surgery may be required, especially in SSP. Chest tubes are used first-line when<unk>  occurs in people with AIDS, usually due to underlying<unk> cystis<unk> nia (PCP), as this condition is associated with prolonged air leakage. Bilateral<unk> <unk>  on both sides) is relatively common in people with<unk> cystis<unk> nia, and surgery is often required. It is possible for a person with a chest tube to be managed in an ambulatory care setting by using a Heimlich valve, although research to demonstrate the equivalence to hospitalization has been of limited quality. Pleurodesis and surgery Pleurodesis is a procedure that permanently eliminates the pleural space and attaches the lung to the chest wall. No long-term study (20 years or more) has been performed on its consequences. Good results in the short term are achieved with a thoracotomy (surgical opening of the chest) with identification of any source of air leakage and stapling of blebs followed by pleurectomy (stripping of the pleural lining) of the outer pleural layer and pleural abrasion (scraping of the pleura) of the inner layer. During the healing process, the lung adheres to the chest wall, effectively obliterating the pleural space. Recurrence rates are approximately 1%. Post-thoracotomy pain is relatively common. Video-assisted thoracoscopic surgery (VATS) wedge resection A less invasive approach is thoracoscopy, usually in the form of a procedure called video-assisted thoracoscopic surgery (VATS). The results from VATS-based pleural abrasion are slightly worse than those achieved using thoracotomy in the short term, but produce smaller scars in the skin. Compared to open thoracotomy, VATS offers a shorter in-hospital stays, less need for postoperative pain control, and a reduced risk of lung problems after surgery. VATS may also be used to achieve chemical pleurodesis; this involves insufflation of talc, which activates an inflammatory reaction that causes the lung to adhere to the chest wall. If a chest tube is already in place, various agents may be instilled through the tube to achieve chemical pleurodesis, such as talc, tetracycline, minocycline or doxycycline. Results of chemical pleurodesis tend to be worse than when using surgical approaches, but talc pleurodesis has been found to have few negative long-term consequences in younger people. Aftercare If<unk>  occurs in a smoker, this is considered an opportunity to emphasize the markedly increased risk of recurrence in those who continue to smoke, and the many benefits of smoking cessation. It may be advisable for someone to remain off work for up to a week after a spontaneous<unk> . If the person normally performs heavy manual labor, several weeks may be required. Those who have undergone pleurodesis may need two to three weeks off work to recover. Air travel is discouraged for up to seven days after complete resolution of a<unk>  if recurrence does not occur. Underwater diving is considered unsafe after an episode of<unk>  unless a preventive procedure has been performed. Professional guidelines suggest that pleurectomy be performed on both lungs and that lung function tests and CT scan normalize before diving is resumed. Aircraft pilots may also require assessment for surgery. Neonatal period For newborn infants with<unk> , different management strategies have been suggested including careful observation, thoracentesis (needle aspiration), or insertion of a chest tube. Needle aspiration may reduce the need for a chest tube, however, the effectiveness and safety of both invasive procedures have not been fully studied.
Pneumothorax
Hemothorax
Pneumatosis
Chylothorax
Costochondritis
Urinothorax
Traumatic cardiac arrest
Hydropneumothorax