The traditional teaching that a pneumothorax that occupies less than 20 per cent of the hemithorax can be observed relates to patients, such as those with primary spontaneous pneumothorax, in whom pulmonary function is well preserved. Drainage indications in critical care patients depend much more on associated pulmonary pathology and cardiopulmonary reserve than on pneumothorax volume.
Small pneumothoraces are still usually well tolerated and can be observed. The onset of tachypnea, distress, discoordinate respiratory pattern, or hemodynamic compromise indicates the need for urgent definitive drainage. Pneumothoraces associated with recent chest trauma or significant obstructive airways disease should be drained as they are likely to increase in size.
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