Pneumothorax and Air Leaks

Abstract Summary Pneumothorax in critically ill patients is a potentially life-threatening condition requiring prompt recognition and management. It occurs most commonly in the context of thoracic trauma or following an invasive procedure, such as mechanical ventilation, central venous catheterization, or thoracentesis. Over the past years, due to the introduction of lung-protective ventilation strategies and the extensive use of ultrasound for central venous catheterization, the incidence of pneumothorax appears to be declining. Pneumothorax can present itself with or without the classic symptoms, which are acute thoracic pain, shortness of breath, tachypnoea, tachycardia, and hypoxia. Additional clinical signs include reduction in lung expansion, diminished breath sounds, and cyanosis. However, these symptoms and signs may be concealed in the context of critically ill, sedated patients. Moreover, occult pneumothorax cannot be recognized by means of a supine chest X-ray, but instead requires thoracic computed tomography or lung ultrasound scanning for diagnosis. To date, no specific guidelines have been published for the treatment of traumatic and iatrogenic pneumothorax in the intensive care setting; however, a consensus exists among experts that the volume of pneumothorax should constitute a determining factor in the decision of whether to insert a chest tube or whether conservative treatment is more appropriate.