BREATHLESS PATIENT74 General Medical Emergencies
(iii) Perform needle aspiration if the air leak has enlarged, or the
patient develops significant breathlessness. Alternatively, insert
a small-bore (<14 F) chest drain intercostal catheter (ICC) using
a Seldinger technique, and admit the patient under the medical
team (see p.471).
3 Needle aspiration (thoracentesis)
Perform this for a symptomatic primary pneumothorax (no CLD) with dysp-
noea, whether large or small; and in a small secondary (with CLD) pneumo-
thorax less than 2 cm with minimal breathlessness if aged under 50 years.
(i) Infiltrate local anaesthetic down to the pleura in the second
intercostal space in the mid-clavicular line.
(ii) Insert a 16-gauge cannula into the pleural cavity, withdraw the
needle, and connect to a 50 mL syringe with three-way tap (see
p.471)
(a) alternatively use a proprietary chest aspiration kit, with
special fenestrated cannula and one-way valve.
(iii) Aspirate air until resistance is felt, the patient coughs excessively,
or more than 2500 mL is aspirated.
(iv) Repeat the CXR; if the lung has re-expanded, observe and repeat
the CXR again after 6 h:
(a) discharge patients with a primary pneumothorax if the lung
remains expanded, and arrange follow-up with the GP and
give discharge advice as above
(b) admit patients with CLD and a secondary pneumothorax
overnight even if aspiration was successful, for continued
observation
(c) proceed directly to insertion of an ICC if aspiration fails,
suggesting a persistent air leak, particularly with a secondary
pneumothorax.
4 Intercostal catheter
This is therefore indicated for:
(i) Failed needle aspiration, e.g. with more than just a small residual
rim of air around the lung.
(ii) Any secondary pneumothorax in a patient with CLD causing
significant dyspnoea, or if aged >50 years.
(iii) Tension pneumothorax following initial needle thoracocentesis.
(iv) Traumatic pneumothorax or haemothorax (see p. 231).
(v) Any pneumothorax prior to anaesthesia or positive-pressure
ventilation.
5 ICC insertion (see p. 473)
(i) Use a small-bore 8–14 French ICC inserted under a Seldinger
technique.