Clinical Procedures - Pneumothorax Aspiration Indications Simple pneumothorax • Aspiration is indicated if the rim of pleural air visible on chest radiograph is >2cm or the patient is breathless • If initial aspiration is unsuccessful, repeat aspiration may be successful in >30% of cases and may avoid intercostal drain insertion • The total volume aspirated should not exceed 2.5L. Secondary pneumothorax • That is, a pneumothorax in the presence of underlying lung disease • Aspiration is only indicated in minimally symptomatic patients with small pneumothoraces (<2cm) aged <50 years. Contraindications • Previous failed attempts at aspiration • Significant secondary pneumothorax • Traumatic pneumothorax. Risks • Pain • Cough • Failure to resolve/recurrence • Re-expansion pulmonary edema may theoretically occur if large volumes (>2.5L) are aspirated. • Tension Pneumothorax In the case of tension pneumothorax, a wide-bore cannula should be inserted into the 2nd intercostal space, midclavicular line without delay and left open to convert the tension pneumothorax to a simple pneumothorax. Equipment • Sterile pack • Sterile gloves • Cleaning solution (e.g. chlorhexidine) • Large-bore (green) cannula • 3-way tap • 50mL syringe • 5mL 1% lidocaine • 23G (blue) needle • 2 x 10mL syringe • Dressing/gauze. Procedure • Pneumothorax is usually aspirated from either the 2nd intercostal space at the midclavicular line or the 4th_ 6th intercostal spaces at the midaxillary line. • Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent • Position the patient leaning back comfortably at about 45° • Identify the site for needle insertion and double-check the radiograph to be certain you have the correct side. Confirm with clinical examination • Clean the area with the chlorhexidine • Infiltrate local anaesthetic down to the pleura using the blue needle and a 10mL syringe • Attach the other 10mL syringe to the cannula and insert the cannula perpendicular to the chest wall, aspirating as you advance until resistance reduces: • D Insert the cannula just above a rib to avoid the neurovascular bundle • Remove the needle and quickly attach the 3-way tap and 50mL syringe • Aspirate with the syringe; close the 3-way tap when the syringe is full, remove the syringe, and eject the air; reattach and open the 3-way tap to continue aspiration: • © The pleural space should never be in continuity with the environment (i.e. tap open with syringe detached) or pneumothorax will re-accumulate • Aspirate until resistance is felt, or up to a maximum of 2.5L • Remove the cannula and apply the dressing • Request chest radiograph to re-assess. Documentation • Date, time, indication, informed consent obtained • Aseptic technique used? • Local anaesthetic used • Site needle inserted • Volume of air aspirated • Any immediate complications • Investigations requested • Signature, printed name, and contact details.
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