Pneumothorax

Pneumothorax
Straight to the point of care
Last updated: Apr 22, 2024
Table of Contents
Overview
3
Summary
3
Definition
3
Theory
4
Epidemiology
4
Risk factors
4
Aetiology
6
Pathophysiology
7
Classification
7
Case history
8
Diagnosis
10
Recommendations
10
History and exam
19
Investigations
22
Differentials
24
Criteria
26
Management
28
Recommendations
28
Treatment algorithm overview
43
Treatment algorithm
46
Emerging
59
Primary prevention
59
Secondary prevention
59
Patient discussions
59
Follow up
60
Monitoring
60
Complications
60
Prognosis
61
Guidelines
62
Diagnostic guidelines
62
Treatment guidelines
62
Online resources
63
References
64
Images
73
Disclaimer
76
Pneumothorax
Overview
Summary
Pneumothorax occurs when air gains access to, and accumulates in, the pleural space.
OVERVIEW
A primary spontaneous pneumothorax occurs in young people without known respiratory illnesses. A
secondary spontaneous pneumothorax occurs in patients with pre-existing pulmonary diseases.
A tension pneumothorax is a medical emergency that requires immediate decompression.
Patients with a pneumothorax typically report dyspnoea and chest pain. In tension pneumothorax, patients
are distressed with rapid laboured respirations, cyanosis, profuse diaphoresis, and tachycardia.
First-line treatment of pneumothoraces depends on a combination of clinical features, and size/type of
pneumothorax. It may include observation with supplemental oxygen therapy, percutaneous aspiration of the
air in the pleural space, insertion of a chest drain, and in some patients video-assisted thoracoscopy (VATS)
or thoracostomy.
Patients with spontaneous pneumothoraces are at risk for recurrence. Pleurodesis (either by mechanical
abrasion or by chemical irritation of pleural surfaces) is used to limit the likelihood of recurrence.
Definition
Pneumothorax occurs when air gains access to, and accumulates in, the pleural space.[1]
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3
Pneumothorax
Theory
THEORY
Epidemiology
In England and Wales, the overall rate of people presenting with pneumothorax (in both primary and
secondary care combined) is 24/100,000 a year for men and approximately 10/100,000 a year for women.[6]
[7] Hospital admission rates are estimated at 16.7/100,000 years for men and 5.8/100,000 years for
women.[7]
Death from spontaneous pneumothorax is rare, with a UK mortality of 1.26 per million a year for men and
0.62 per million a year for women.[6] Smoking increases the likelihood of spontaneous pneumothorax by 22
times for men and by 9 times for women, compared with not smoking. The incidence is directly related to the
amount smoked.[8]
Risk factors
Strong
cigaret te smoking
The estimated lifetime risk of developing a pneumothorax in healthy smoking men is approximately
12%, compared with 0.1% in non-smokers. Small-airway inflammation from tobacco smoke may
contribute to the development of subpleural blebs.[8] [18]
family history of pneumothorax
There seems to be a familial tendency for primary spontaneous pneumothoraces. There may be either
autosomal-dominant with incomplete penetrance or X-linked recessive inheritance.[19] [20]
tall and slender body build
Patients with primary spontaneous pneumothoraces are usually taller and thinner than control
patients. The alveoli at the lung apex are subjected to a greater mean distending pressure in taller
patients, leading to the development of subpleural blebs and other abnormalities.[21] [22]
age <40 years
The peak age for primary spontaneous pneumothorax is 20 years at the first episode. Primary
spontaneous pneumothoraces rarely occur after 40 years of age.[21]
recent invasive medical procedure
Invasive procedures such as transcutaneous needle aspiration of lung lesions, thoracentesis,
endoscopic transbronchial biopsy, and central venous catheter placement are associated with
iatrogenic pneumothoraces.
chest trauma
Pneumothoraces are seen in as many as 40% to 50% of chest trauma victims.[23] [24] [25]
acute severe asthma
The air trapping associated with airway inflammation during an asthmatic attack can cause rupture of
alveolar sacs leading to the development of a pneumothorax.[1]
4
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Pneumothorax
Theory
COPD
This is the leading cause of secondary spontaneous pneumothoraces and is due to rupture of
subpleural emphysematous blebs.[26]
THEORY
tuberculosis
Secondary spontaneous pneumothoraces occur in 1.5% of cases of active pulmonary tuberculosis.
Ruptures of subpleural tuberculous cysts are thought to be responsible.[27]
AIDS-related Pneumocystis jirovecii infection
Pneumocystis jirovecii necrotic subpleural cyst may cause pneumothorax in patients with a history of
HIV infection and AIDS.[22]
About 2% to 5% of patients with AIDS develop a secondary spontaneous pneumothorax.[22]
cystic fibrosis
Secondary spontaneous pneumothorax is a frequent occurrence in cystic fibrosis and is associated
with more severe disease. About 16% to 20% of patients with cystic fibrosis >18 years of age will
experience a pneumothorax at some time in their lives. Recurrent contralateral pneumothoraces occur
in 40% of patients.[28] [29]
lymphangioleiomyomatosis
A multi-system disease of women, characterised by cystic lung destruction that can result in recurrent
pneumothoraces.[30]
Birt-Hogg-Dube syndrome
An autosomal dominant inheritable disease characterised by pulmonary cysts, spontaneous
pneumothoraces, benign skin lesions, and renal cancers. Mutations in the gene that encodes for
folliculin have been identified in individuals with this familial spontaneous pneumothorax.[35]
pulmonary Langerhans cell histiocytosis
This is a smoking-related interstitial lung disease, characterised by the development of cystic changes
in the lung that predisposes to pneumothorax.[36]
Erdheim-Chester disease
A rare disease characterised by disseminated non-Langerhans cell histiocytosis involving multiple
organs. Pulmonary involvement is uncommon but the lung can become infiltrated by lipid-laden
histiocytes, resulting in diffuse interstitial cystic changes and pneumothorax.[37]
Weak
Marfan syndrome
There are reports of families afflicted with Marfan syndrome whose members suffered multiple
bilateral episodes of primary spontaneous pneumothoraces. In this population, primary spontaneous
pneumothoraces are attributed to pulmonary tissue fragility related to defective fibrillin.[31]
homocystinuria
There have been a few case reports of primary spontaneous pneumothoraces in patients with
homocystinuria. The pathophysiology of this association is unknown.[32]
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5
Pneumothorax
Theory
THEORY
primary lung cancer and metastatic cancer to the lungs
Pneumothorax can occur in bronchogenic carcinomas and in a variety of cancers that have
metastasised to the lungs. The pneumothoraces can develop following chemotherapy. It is postulated
that necrosis of the peripherally located cancer causes the tumour to rupture into the pleural space,
resulting in a pneumothorax.[33] [34]
Aetiology
General risk factors for spontaneous pneumothorax include:
• Smoking[9] [10]
• This is the most important risk factor; men who smoke increase their risk of a first pneumothorax
22-fold and women 9-fold compared with non-smokers[8]
• Family history of pneumothorax[11]
• Tall and slender body build[10]
• Male sex[10]
• Young age[10]
• However, secondary spontaneous pneumothorax is more common in people aged >55 years
• Presence of underlying lung disease such as:[9]
• COPD
• Severe asthma
• Tuberculosis
• Pneumocystis jirovecii infection
• Cystic fibrosis
• Structural abnormalities (e.g., Marfan syndrome, Ehlers-Danlos syndrome)[12]
• Homocystinuria[11]
• Menstruation
• Catamenial pneumothorax occurs in recurrent episodes within 72 hours before or after the start
of menstruation. It is rare but thought to be underdiagnosed.[10] [13]
A traumatic pneumothorax results from either penetrating or blunt injury to the chest.[14]
A tension pneumothorax can complicate primary and secondary spontaneous pneumothoraces as well as
traumatic pneumothoraces. It is also more likely in patients with the following risk factors:
• Ventilated patients
• Following trauma (especially penetrating chest wounds) or cardiopulmonary resuscitation
• Lung disease, especially acute presentations of asthma and bullous COPD, or in long-standing
underlying lung disease such as cystic fibrosis, bronchiectasis, fibrotic lung diseases, or lung cancer
• Blocked chest drain
• Patients receiving non-invasive ventilation (NIV)
6
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Pneumothorax
Theory
• Other (e.g., hyperbaric oxygen treatment)
THEORY
Pneumothorax ex vacuo may occur following an invasive medical procedure (e.g., drainage of pleural
effusion or CT-guided lung biopsy).[15] [16]
Pathophysiology
Pneumothorax refers to gas within the pleural space. Normally, the alveolar pressure is greater than the
intrapleural pressure, while the intrapleural pressure is less than atmospheric pressure. Therefore, if a
communication develops between an alveolus and the pleural space, or between the atmosphere and the
pleural space, gases will follow the pressure gradient and flow into the pleural space. This flow will continue
until the pressure gradient no longer exists or the abnormal communication has been sealed. Because the
thoracic cavity is normally below its resting volume, and the lung is above its resting volume, the thoracic
cavity enlarges and the lung becomes smaller when a pneumothorax develops.[1]
A tension pneumothorax is a medical emergency and occurs when the intrapleural pressure exceeds
atmospheric pressure, especially during expiration, and results from a ball valve mechanism that promotes
inspiratory accumulation of pleural gases. The build-up of pressure within the pleural space eventually results
in hypoxaemia and respiratory failure from compression of the lung.[1]
The pathophysiology of catamenial pneumothoraces is not known. It has been suggested that air gains
access to the peritoneal cavity during menstruation and then secondarily the pleural space through
diaphragmatic defects.[17] Alternatively, it has been hypothesised that ectopic intrathoracic endometriosis
results in visceral pleural erosions, thus causing a pneumothorax.[9]
Classification
Clinical classification[2]
Spontaneous pneumothorax: occurs without preceding trauma or precipitating event. This type of
pneumothorax is further subdivided into the following:
• This type of pneumothorax is further subdivided into the following:
• Primary pneumothorax: occurs without clinically apparent pulmonary disease
• Secondary pneumothorax: occurs as a complication of an underlying pulmonary disease,
including COPD, asthma, and thoracic endometriosis (catamenial pneumothorax).
• The distinction between primary and secondary spontaneous pneumothorax is becoming increasingly
blurred in practice. Seek senior or specialist advice if you are in any doubt about which type of
pneumothorax your patient has.
• In theory, a patient with any underlying respiratory diagnosis should be considered to have
a secondary, rather than primary, spontaneous pneumothorax. Most cases of secondary
spontaneous pneumothorax are in patients with COPD.[3]
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7
Pneumothorax
Theory
THEORY
• However, in practice, a patient with a history of only very mild respiratory disease might
be managed as a primary spontaneous pneumothorax - for example, a patient with mild,
intermittent asthma with no exacerbation of symptoms at presentation with the pneumothorax.
Traumatic pneumothorax: results from either penetrating or blunt injury to the chest. These may be the result
of accidental or non-accidental injury.
Iatrogenic pneumothorax is a form of accidental traumatic pneumothorax, and occurs as a result of
complications related to medical interventions. These include:
• Medical procedures such as transcutaneous needle aspiration of lung lesions, thoracentesis,
endoscopic transbronchial biopsy, and central venous catheter placement, as well as barotrauma as a
result of mechanical ventilation.
Tension pneumothorax: occurs when the intrapleural pressure exceeds atmospheric pressure throughout
expiration and often during inspiration. It is a medical emergency that requires prompt decompression.
Pneumothorax ex vacuo: a rare form of pneumothorax that occurs when rapid collapse of the lung produces
a decrease in the intrapleural pressure. It is most commonly seen in atelectasis of the right upper lobe. The
increased negative intrapleural pressure causes gaseous nitrogen molecules to migrate from the pulmonary
capillaries into the pleural space.[4]
Case history
Case history #1
A 20-year-old man presents to the emergency department with complaints of left-sided chest pain and
shortness of breath. He states that these symptoms began suddenly 4 days ago while he was working at
his computer. He initially thought that he might have strained a chest wall muscle, but because the pain
and dyspnoea had not resolved, he decided to seek medical attention. He has no significant past medical
history but has smoked cigarettes since the age of 16 years. His older brother suffered a pneumothorax
at the age of 23 years. The patient's vital signs are normal. He appears in mild discomfort. Examination of
his chest reveals that the left hemithorax is mildly hyperexpanded with decreased chest excursion. His left
hemithorax is hyper-resonant on percussion, and breath sounds are diminished when compared with the
right hemithorax. His cardiovascular examination is normal.
Case history #2
A 65-year-old patient with COPD presents to the emergency department with complaints of worsening
shortness of breath and right-sided chest discomfort. He states that these symptoms occurred suddenly 1
hour prior to presentation. He denies fevers and chills. He also denies increased sputum production and a
change in the colour or character of his sputum. He continues to smoke cigarettes against medical advice.
The patient's blood pressure is 136/92 mmHg, heart rate is 110 beats per minute, and respiratory rate is
24 breaths per minute. Chest excursion is decreased on the right more than the left. His right hemithorax
is more hyperinflated than the left. His right hemithorax is hyper-resonant on percussion. Breath sounds
are distant bilaterally but more diminished on the right.
8
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Pneumothorax
Theory
Other presentations
THEORY
Atypical presentations include a patient with pleural gases accumulated at the site of atelectatic lung
(known as pneumothorax ex vacuo). In this instance the patient may present with cough or dyspnoea
related to the degree of collapse.
Catamenial pneumothoraces occur within 72 hours before or after menstruation in young women.
They are thought to be relatively rare, with approximately 250 cases described in the medical literature,
although they may be under-reported. These pneumothoraces are typically right-sided.[5]
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9
Pneumothorax
Diagnosis
Recommendations
Urgent
Suspect a tension pneumothorax if there is sudden onset of:[9] [10] [39]
• Cardiopulmonary deterioration
• Hypotension; this suggests imminent cardiac arrest
• Respiratory distress
• Low oxygen saturations
• Tachycardia
• Shock
• Loss of consciousness
• Severe chest pain
• Sweating.
Examine for ipsilateral reduced breath sounds, reduced chest expansion, hyper-resonance on percussion,
and tracheal shift to the contralateral side.[9]
Put out an immediate cardiac arrest call and give high-flow ox ygen. Perform emergency needle
decompression; do not wait for imaging to confirm the diagnosis. Insert a chest drain following this.[9] [40]
[41] See Management Recommendations.
Maintain a high level of suspicion for a tension pneumothorax in a patient with any of the following risk
factors:[42] [9]
DIAGNOSIS
• Ventilated patients
• Following trauma (especially penetrating chest wounds) or cardiopulmonary resuscitation
• Lung disease, especially acute presentations of asthma and bullous COPD, or long-standing lung
disease such as cystic fibrosis, bronchiectasis, fibrotic lung disease, or lung cancer
• Blocked chest drain
• Patients receiving non-invasive ventilation (NIV)
• Other (e.g., hyperbaric oxygen treatment).
Key Recommendations
Suspect a non-tension pneumothorax in a stable patient who has sudden onset of chest pain,
dyspnoea, or cough, especially if they have risk factors such as smoking or underlying lung
disease.[9] [43] [10]
• Symptoms tend to be more severe in secondary spontaneous pneumothorax and may be minimal
or absent in primary spontaneous pneumothorax.[9] [44] [10]
• Chest pain is usually pleuritic.[9] [44] [10]
• Signs on examination include:
• Ipsilateral reduced breath sounds[9] [10]
• Ipsilateral hyperinflation of the hemithorax with hyper-resonance on percussion[10]
• Hypoxia; this is generally a late sign[39] [45]
10
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Diagnosis
Pneumothorax
• Evidence of penetrating trauma or rib fractures in a traumatic pneumothorax.[42]
Use erect postero-anterior (PA) chest x-ray as the first-line investigation to definitively diagnose a
pneumothorax in a stable patient who can sit upright.[9]
• Order a CT chest if the diagnosis is uncertain on chest x-ray and the patient remains symptomatic,
or in stable patients with significant chest trauma.[9] [46] If the patient is stable, discuss with a
radiologist.
• If pneumothorax is diagnosed, measure the visible rim between the lung margin and the
chest wall at the level of the hilum on imaging to help guide further management.[9]
• Large pneumothorax: visible rim >2 cm
• Small pneumothorax: visible rim ≤2 cm
Full Recommendations
Clinical presentation
Tension pneumothorax is a life-threatening emergency that needs urgent identification and treatment
with decompression and high-flow oxygen; do not wait for imaging to confirm the diagnosis.[9] See
Management Recommendations.
Signs are typically sudden in onset and include:[9] [10]
• Cardiopulmonary deterioration
DIAGNOSIS
• Hypotension; this suggests imminent cardiac arrest
• Respiratory distress
• Low oxygen saturations
• Tachycardia
• Shock
• See our topic Shock
• Loss of consciousness
• Severe chest pain
• Sweating.
Practical tip
Tension pneumothorax is extremely rare in a primary spontaneous pneumothorax (PSP).[10]
However, significant breathlessness in a patient with a small PSP may indicate the development of
a tension pneumothorax.[47]
Other concerning symptoms in a patient with a small PSP that may indicate the development of a
tension pneumothorax are chest pain, feeling of dread or panic, excessive sweating, agitation, and
confusion.[41] [9]
General features of a non-tension pneumothorax also tend to be sudden in onset and include:
• Chest pain [9]
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11
Pneumothorax
Diagnosis
• Typically pleuritic[9] [10]
• Some patients with PSP may experience shoulder tip pain instead[10]
• Dyspnoea [9]
• More prominent in secondary spontaneous pneumothorax (SSP)[10]
• Cough
• Sometimes present in pneumothorax ex vacuo (commonly known as ‘trapped lung’).[43]
Symptoms of SSP are generally more severe than symptoms of PSP due to coexistent lung disease, and
may be present even with relatively small pneumothoraces. Symptoms may be very mild or absent in
PSP.[9] [44] [10]
Practical tip
Symptoms usually improve following presentation of PSP. If symptoms worsen, consider the
development of complications such as tension pneumothorax or haemopneumothorax, or an
alternative cause of symptoms.[10]
Examination
Look for tracheal shift to the contralateral side, which indicates a tension pneumothorax, although
examination can be challenging in this setting.[39] [9]
Look for other general signs of a pneumothorax:
• Ipsilateral reduced breath sounds[9] [10]
• This is the most common sign in tension pneumothorax[9]
• Ipsilateral hyperinflation of the hemithorax with hyper-resonance on percussion[10]
DIAGNOSIS
• However, hyperinflation may be difficult to detect clinically in a tension pneumothorax, and is
not present in a pneumothorax ex vacuo
• Hypoxia
• Generally a late sign
• More common in tension pneumothorax and SPP[39] [45]
• Evidence of penetrating trauma or rib fractures in a traumatic pneumothorax.[42]
Remember there may also be signs of underlying lung disease (e.g., COPD) if the pneumothorax is
secondary.[9]
Risk factors
Maintain a high level of suspicion for a tension pneumothorax in a patient with any of the following risk
factors:[40] [42] [9]
• Ventilated patients
• Following trauma (especially penetrating chest wounds) or cardiopulmonary resuscitation
12
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Pneumothorax
Diagnosis
• Lung disease, especially acute presentations of asthma and bullous COPD, or in long-standing
underlying lung disease such as cystic fibrosis, bronchiectasis, fibrotic lung diseases, or lung
cancer
• Blocked chest drain
• Patients receiving non-invasive ventilation (NIV)
• Other (e.g., hyperbaric oxygen treatment).
Practical tip
Maintain a high level of suspicion for a tension pneumothorax in patients using ventilators who have
a rapid onset of haemodynamic instability or cardiac arrest, particularly if they require increasing
peak inspiratory pressures.[42]
Consider other general risk factors for pneumothorax, including:
• Smoking[9] [10]
• This is the most important risk factor; men who smoke increase their risk of a first
pneumothorax 22-fold and women 9-fold compared with non-smokers[8]
• Family history of pneumothorax[11]
• Tall and slender body build[10]
• Male sex[10]
• Young age[10]
• However, secondary spontaneous pneumothorax is more common in people aged >55 years
• Presence of underlying lung disease such as:[9]
DIAGNOSIS
• COPD
• Severe asthma
• Tuberculosis
• Pneumocystis jirovecii infection
• Cystic fibrosis
• Structural abnormalities (e.g., Marfan syndrome, Ehlers-Danlos syndrome)[12]
• Recent invasive medical procedures (e.g., drainage of pleural effusion or CT-guided lung
biopsy)[15] [16]
• Trauma[14]
• Homocystinuria[11]
• Menstruation
• Catamenial pneumothorax occurs in recurrent episodes within 72 hours before or after the
start of menstruation. Suspect this in women with recurrent pneumothorax and a history of
endometriosis. It is rare but thought to be underdiagnosed.[10] [13]
Investigations
Use imaging to definitively diagnose a pneumothorax and to measure the size of the pneumothorax.
However, clinical evaluation is more important than the size of the pneumothorax in determining further
management.[9]
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13
Diagnosis
Pneumothorax
Chest x-ray (always order)
Use chest x-ray as the first-line investigation in stable patients who can sit upright to definitively diagnose
pneumothorax.[9]
• Order an erect postero-anterior (PA) chest x-ray in inspiration.[9]
• Look for:
DIAGNOSIS
• A visible rim between the lung margin and the chest wall or surgical emphysema[9] [48]
• Absence of lung markings between the lung margin and chest wall.[10]
Anterior-posterior chest x-ray demonstrating a right pneumothorax
From the collection of Dr Ryland P. Byrd
Practical tip
Potential mimics of a pneumothorax on chest x-ray are:[49] [9]
• Bullous lung disease
• Medial border of the scapula
• Outline of the oxygen reservoir bag or associated tubing
• Clothing
• Bedsheets
• Companion shadows (visible subcostal groove usually at ribs 1 and 2)
• Skin folds
• Post-pleurectomy scarring/suture material.
14
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Pneumothorax
Diagnosis
Evidence: Chest x-ray for diagnosis of pneumothorax
Guidelines recommend erect inspiratory chest x-ray or CT scan, based on varying levels of
evidence. [9] [10]
The 2010 British Thoracic Society (BTS) guideline states that an erect inspiratory chest xray should be used where possible rather than expiratory films. [9]
• This is based on “Grade A” evidence, defined in the BTS guideline as: at least one metaanalysis, systematic review, or randomised controlled trial (RCT) rated as 1++ (very low risk
of bias) and directly applicable to the target population; or a systematic review of RCTs or a
body of evidence consisting principally of studies rated as 1+ (well-conducted meta-analyses,
systematic reviews of RCTs, or RCTs with low risk of bias) directly applicable to the target
population and demonstrating overall consistency of results.[9]
• Alternative x-ray methods have been used including lateral, expiratory, supine, and lateral
decubitus x-rays, but these have no advantages over inspiratory x-rays or CT scans.[9]
Chest CT scan is considered the “gold standard” for diagnosing pneumothorax,
especially if other lung diseases are also present, and is recommended for uncertain or
complex cases. [9]
• This is based on “Grade D” evidence, defined in the BTS guideline as: evidence level 3 or 4
(non-analytical studies or expert opinion); or extrapolated evidence from studies rated as 2+
(well-conducted case-control or cohort studies with a low risk of confounding, bias, or chance
and a moderate probability that the relationship is causal).[9]
• In critically ill patients, pneumothoraces in the anteromedial and subpulmonic recesses may
not be detected by the clinician or radiologist on initial views, and may progress to tension
pneumothorax, so CT should be used in such patients.[50]
If pneumothorax is confirmed on imaging, measure the visible rim between the lung margin and
the chest wall at the level of the hilum. This can be done using chest x-ray but is most accurately
measured using CT.[9]
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DIAGNOSIS
• Large pneumothorax: visible rim >2 cm
• Small pneumothorax: visible rim ≤2 cm
15
DIAGNOSIS
Pneumothorax
Diagnosis
UK guidelines advise using the level of the hilum to measure the size of a pneumothorax. However, other
countries may use other methods; for example US guidelines use the distance from the lung apex to
the cupola, but this method would tend to overestimate the volume of a localised apical pneumothorax.
Copyright © BMJ Publishing Group Ltd and British Thoracic Society. All rights reserved.
Note that the size of pneumothorax on imaging does not correlate well with the clinical presentation of the
patient.[9]
• A 2 cm visible rim corresponds to a pneumothorax of about 50% (complete collapse of the lung is a
100% pneumothorax).[42]
16
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Diagnosis
Pneumothorax
Evidence: Measurement of size of pneumothorax
Guidelines agree that the size of the pneumothorax should be measured, but vary on how this
should be done.
• The 2010 British Thoracic Society guideline indicates the size should be measured at the level
of the hilum with a cut-off value of 2 cm to define small versus large pneumothorax.[9]
• A 2001 US guideline recommends measuring the size from the apex to the cupola with a cut off
of 3 cm to define small versus large pneumothorax.[38]
• A 2005 Belgian guideline states that a large pneumothorax is defined by a pleural gap along the
entire length of the lateral chest wall.[51]
A retrospective study of 49 episodes of pneumothorax demonstrated poor agreement
between the methods of classification in these three guidelines. [52]
• Classifications from x-rays using the three guideline methods were compared with estimates of
actual pneumothorax volumes based on CT scans.
• The UK guideline cut-off identified 5 of the 49 episodes as large pneumothoraces (10%) and
had good specificity as the identified patients had actual volumes between 45% and 100%.[9]
• The US and Belgian guideline methods identified much higher proportions of patients as having
large pneumothoraces (49% and 47%, respectively), but specificity was poorer as the identified
patients actually had volumes between 21% to 100% and 12% to 100%, respectively.[38] [51]
Blood tests (always order)
Order a full blood count and clotting screen.
•
9
Correct clotting abnormalities (INR ≥1.5 or platelets ≤50 x 10 /L) before inserting a chest drain in
patients who are not critically unwell.[9] [53]
Chest ultrasound (consider ordering)
DIAGNOSIS
Chest ultrasound is increasingly used to detect pneumothorax, especially for patients who are
immobilised following trauma, when an erect PA chest x-ray cannot be obtained. It requires specialist
expertise.[54] [55] [56]
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17
Diagnosis
Pneumothorax
Evidence: Ultrasound for diagnosis of pneumothorax
Ultrasound may be helpful for trauma patients who are unable to undergo erect chest x-ray. [9]
One Cochrane systematic review (search date April 2020) compared chest ultrasound by frontline
non‐radiologist physicians with portable supine anterior-posterior chest x-ray for the diagnosis of
pneumothorax in trauma patients in the emergency department. CT of the chest or tube thoracostomy
were used as the reference standard.[56]
• It found 13 prospective, paired accuracy studies of which 9 (410 patients with traumatic
pneumothorax) used patients, as opposed to lung field, as the unit of analysis.
• All studies were at high or unclear risk of bias in at least one domain.
• Chest ultrasound was more sensitive than chest x-ray (ultrasound 0.91, 95% CI 0.85 to 0.94;
chest x-ray 0.47, 95% CI 0.31 to 0.63). Both had high specificity with no significant difference
between chest ultrasound and x-ray for specificity.
• This means that (assuming a prevalence of 30%) there would be around 5 times the numbers
of missed traumatic pneumothorax (false negatives) with chest x-ray compared with ultrasound,
whilst both have very low false positive rates.
• Further analyses found these results were independent of the type of trauma (blunt or
penetrating), ultrasound operator, or type of ultrasound probe used.
However, the accuracy of ultrasound for spontaneous pneumothorax is unclear, so conventional
radiology should be used to diagnose spontaneous pneumothorax.[57]
• The accuracy of ultrasound for pneumothorax diagnosis compared with chest radiography has
been assessed in 4 meta-analyses, described in a clinical review.[58] [59] [60] [61] [57]
• Pooled ultrasound sensitivity was 78% to 90% and pooled specificity was >98%.
• The patients were mainly trauma and critically ill patients, or had undergone
DIAGNOSIS
percutaneous thoracic procedures, so the results may not be applicable to patients
presenting with suspected spontaneous pneumothorax.
• All the meta-analyses found high heterogeneity, possibly due to operator performance.
A retrospective study of 357 patients in intensive care (47 with occult pneumothorax and 310 controls)
compared specific signs on ultrasound with CT scan for detection of occult pneumothorax.[62] [63]
• For the diagnosis of occult pneumothorax, ‘absence of lung sliding’ (occurs when the visceral
pleura does not slide against the parietal pleura) alone as a sign on ultrasound imaging had a
sensitivity of 100% and a specificity of 78%.
• ‘Absent lung sliding’ plus the ‘A line sign’ (horizontal lines below the pleura caused by the
presence of air) on ultrasound imaging had a sensitivity of 95% and a specificity of 94%.
• The presence of ‘lung point’ (the point at which the two pleural layers rejoin one another from
a pneumothorax) as a sign on ultrasound imaging had a sensitivity of 79% and a specificity of
100%.
CT chest (consider ordering)
Order a CT chest if the diagnosis is uncertain on chest x-ray and the patient remains symptomatic, or in
stable patients with significant chest trauma. If the patient is stable discuss this with a radiologist.[9] [46]
18
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Pneumothorax
Diagnosis
CT chest is considered the gold standard for accurate assessment of the size of the pneumothorax.[9]
CT chest can also be used to:[64]
• Differentiate pneumothorax from bullous lung disease
• Identify underlying lung disease in patients with secondary spontaneous pneumothorax.
Arterial blood gas (consider ordering)
Consider an arterial blood gas (ABG) if oxygen saturations are ≤92% on room air.[9] It may help rule out
other differential diagnoses but is not usually necessary.
• Escalate to a senior colleague if there is acute respiratory acidosis.
• Respiratory alkalosis is the most common finding.[65]
History and exam
Key diagnostic factors
chest pain (common)
Typically pleuritic.[10]
Some patients with primary spontaneous pneumothorax may experience shoulder tip pain instead.[10]
dyspnoea (common)
More prominent in secondary spontaneous pneumothorax.[10]
ipsilateral reduced breath sounds (common)
DIAGNOSIS
This is the most common sign in tension pneumothorax but may also be present in a non-tension
pneumothorax.[9]
ipsilateral hyperinflation of the hemithorax with hyper-resonance on
percussion (common)
Hyperinflation may be difficult to detect clinically in a tension pneumothorax, however, and is not
present in a pneumothorax ex vacuo (commonly known as ‘trapped lung’).[39] [9]
hypoxia (common)
Generally a late sign. More common in tension pneumothorax and secondary spontaneous
pneumothorax.[39] [45]
presence of risk factors (common)
Smoking[9] [10]
• This is the most important risk factor; men who smoke increase their risk of a first pneumothorax
22-fold and women 9-fold compared with non-smokers.[8]
Family history of pneumothorax
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19
Diagnosis
Pneumothorax
• A risk factor for pneumothorax.[11]
Tall and slender body build
• Increases the risk of pneumothorax.[10]
Male sex
• A risk factor for pneumothorax.[10]
Young age
• However, secondary spontaneous pneumothorax is more common in people aged >55
years.[10]
Presence of underlying lung disease
• Lung disease that increases the risk of pneumothorax includes:[9]
• COPD
• Severe asthma
• Tuberculosis
• Pneumocystis jirovecii infection
• Cystic fibrosis.
• In particular, acute presentations of asthma and bullous COPD, or long standing lung disease
such as cystic fibrosis, bronchiectasis, fibrotic lung diseases, or lung cancer may increase the
risk of a tension pneumothorax.[42] [9]
DIAGNOSIS
Structural abnormalities
• These include Marfan syndrome and Ehlers-Danlos syndrome.[12]
Recent invasive medical procedures
• These include drainage of pleural effusion or CT-guided lung biopsy.[15] [16]
Trauma
• Penetrating chest wounds and cardiopulmonary resuscitation are a particular risk factor for a
tension pneumothorax.[42] [9] [14]
Homocystinuria
• A risk factor for pneumothorax.[11]
Menstruation
20
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Pneumothorax
Diagnosis
• Catamenial pneumothorax occurs in recurrent episodes within 72 hours before or after the
start of menstruation. Suspect this in women with recurrent pneumothorax and a history of
endometriosis. It is rare but thought to be underdiagnosed.[10] [13]
Ventilated patients
• A risk factor for a tension pneumothorax.[42] [9]
Blocked chest drain
• A risk factor for a tension pneumothorax.[42] [9]
Non-invasive ventilation (NIV)
• A risk factor for a tension pneumothorax.[42] [9]
Hyperbaric oxygen treatment
• A risk factor for a tension pneumothorax.[40]
cardiopulmonary deterioration (uncommon)
This is a feature of a tension pneumothorax and is typically sudden in onset. It includes:[9] [10] [39]
• Hypotension; this suggests imminent cardiac arrest
• Respiratory distress
• Low oxygen saturations
• Tachycardia
• Shock
• Loss of consciousness.
DIAGNOSIS
trachea shifted to the contralateral side (uncommon)
This is a feature of a tension pneumothorax.[9]
sweating (uncommon)
This is a feature of a tension pneumothorax.[9] [10] [39]
Other diagnostic factors
cough (uncommon)
Sometimes present in pneumothorax ex vacuo (commonly known as ‘trapped lung’).[43]
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21
Diagnosis
Pneumothorax
Investigations
1st test to order
Test
Result
chest x-ray
Use chest x-ray as the first-line investigation in stable patients who
can sit upright to definitively diagnose pneumothorax.[9]
• Order an erect postero-anterior (PA) x-ray in inspiration.[9]
• a visible rim between
the lung margin and
chest wall, or surgical
emphysema[9] [48]
• absence of lung
markings between the
lung margin and chest
wall[10]
DIAGNOSIS
Anterior-posterior chest x-ray demonstrating a right pneumothorax
From the collection of Dr Ryland P. Byrd
blood tests
baseline levels
Order a full blood count and clotting screen.
• Correct clotting abnormalities (INR ≥1.5 or platelets ≤50 x
10⁹/L) before inserting a chest drain in patients who are not
critically unwell.[9] [53]
22
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Diagnosis
Pneumothorax
Other tests to consider
Test
Result
chest ultrasound
Chest ultrasound is increasingly used to detect pneumothorax,
especially for patients who are immobilised following trauma, when
an erect PA chest x-ray cannot be obtained. It requires specialist
expertise.[54] [55] [56]
CT chest
Order a CT chest if the diagnosis is uncertain on chest x-ray and the
patient remains symptomatic, or in stable patients with significant
chest trauma. If the patient is stable discuss this with a radiologist.[9]
[46]
Consider an ABG if oxygen saturations are ≤92% on room air.[9] It
may aid in ruling out other differential diagnoses but is not usually
necessary.
• presence of a visible
visceral pleural line
• there may be
atelectasis of lung or
hyperexpansion of
ipsilateral hemithorax;
there may also be a
partially adherent lung;
CT guides the best
place to insert a chest
drain[67]
• in secondary
spontaneous
pneumothorax there
may be signs of
underlying lung disease
• acute respiratory
acidosis; escalate to a
senior colleague if this
is present
• respiratory alkalosis
is the most common
finding[65]
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23
DIAGNOSIS
arterial blood gas (ABG)
• absence of lung sliding
(occurs when the
visceral pleura does
not slide against the
parietal pleura[62] [63]
• the ‘A line’ sign
(horizontal lines below
the pleura caused by
the presence of air)[62]
[63]
• presence of ‘lung
point’ (the point
at which the two
pleural layers rejoin
one another from a
pneumothorax)[62] [63]
• ‘barcode sign’ (in M
mode) where there is
a pattern of parallel
horizontal lines above
and below the pleural
line[66]
Diagnosis
Pneumothorax
Differentials
DIAGNOSIS
Condition
Differentiating signs / Differentiating tests
symptoms
Asthma, acute
exacerbation
• Expiratory wheeze and chest
tightness.[68]
•
Therapeutic trial of
bronchodilators relieves
symptoms.
COPD, acute exacerbation
• Fever, increased cough,
and change in sputum
colour suggest an infective
exacerbation. Bullous
pulmonary disease may,
however, be clinically
indistinguishable from
pneumothorax.[68]
•
Usually, a chest x-ray will
suffice but a CT of the
chest may be necessary to
differentiate a pneumothorax
from a pulmonary bulla.[49]
Pulmonary embolism
• Presence of risk factors
for thromboembolism,
such as obesity, prolonged
bed rest, pregnancy/
postpartum period, inherited
thrombophilias, active
malignancy, recent trauma/
fracture, and a history
of previous thrombosis.
Physical examination
abnormalities suggestive
of deep venous thrombosis
are present in 50% of
patients.[2]
•
The chest x-ray is most
commonly normal, but
atelectasis may be present.
Pulmonary infiltrates may
develop and can be of any
shape, not just wedgeshaped.
CT pulmonary angiogram
with direct visualisation of
thrombus in a pulmonary
artery.
Ventilation-perfusion scan
(V/Q scan) with an area
of ventilation that is not
perfused.
• Typically the patient
complains of chest tightness
and shortness of breath that
is brought on by exertion.
The chest discomfort is
usually substernal and is
described as a pressure
sensation. Pain may radiate
into the neck and down the
arms. Nausea, vomiting, and
diaphoresis may accompany
the chest discomfort.
•
• Patients will experience
pain. However, as fluid
accumulates in the pleural
space, the visceral and
parietal pleura will move
apart and chest pain will
ease. Physical examination
demonstrates decreased
fremitus, dullness to
percussion, and decreased
•
Myocardial ischaemia
Pleural effusion
24
•
•
•
An ECG may demonstrate
ischaemia or injury patterns.
Serum levels of troponin
increase when myocardial
infarction has occurred.
A chest x-ray is typically
diagnostic of a pleural
effusion. A meniscus sign
at the costophrenic angle
in an upright chest x-ray is
diagnostic. An effusion as
small as 50 mL can be seen
on the lateral film and more
than a few hundred millilitres
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Diagnosis
Pneumothorax
Condition
Differentiating signs / Differentiating tests
symptoms
breath sounds. As pleural
fluid accumulates, the patient
may experience shortness of
breath. Patients may develop
post-drainage pneumothorax
ex vacuo in the setting of
unexplainable lung condition
(no intervention is generally
needed in this case).
•
will be visible on the posteroanterior film.
CT scans are more sensitive
and may give additional
clues to the clinician
concerning the aetiology of
the pleural fluid.
• A bronchopleural fistula is
a communication between
the pleural space and the
bronchial tree that persists
for 24 hours or more. The
most common cause is
postoperative complication
of pulmonary resections.
Other aetiologies include
lung necrosis complicating
infection, persistent
spontaneous pneumothorax,
chemotherapy or
radiotherapy for
bronchogenic carcinoma
and metastatic cancer to the
lung, and tuberculosis.
• The presentation is
characterised by sudden
appearance of dyspnoea,
hypotension, subcutaneous
emphysema, cough, and
purulent sputum, and
shifting of the trachea and
mediastinum.[69]
•
The diagnosis is established
by placing a chest tube
or small-bore catheter
into a pneumothorax and
demonstrating a persistent
air leak.
Fibrosing lung disease
• Patients typically complain
of slowly progressive
dyspnoea. Crackles are
present on auscultation
of the chest. A prominent
second heart sound may
also be evident. The patient
may have digital clubbing.
•
A chest x-ray is often
the initial radiological
examination when fibrotic
lung disease is suspected.
CT scanning, however, is
more sensitive and helps in
determining whether there
is an active inflammatory
disease of the lung. A
ground-glass infiltrate
indicates that alveolitis is
present.
Further diagnostic studies
and therapeutic interventions
may be necessary.
•
•
Oesophageal perforation
• Oesophageal perforations
most commonly occur after
medical instrumentation
or para-oesophageal
•
Plain chest radiography is
almost always abnormal
in oesophageal rupture.
Early in the course of the
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25
DIAGNOSIS
Bronchopleural fistula
Diagnosis
Pneumothorax
Condition
Differentiating signs / Differentiating tests
symptoms
surgery, and following
sudden increase in intraoesophageal pressure
combined with negative
intrathoracic pressure
caused by straining or
vomiting (Boerhaave's
syndrome).
• Patients complain of severe
retrosternal chest and
upper abdominal pain.
Odynophagia, tachypnoea,
dyspnoea, cyanosis, fever,
and shock develop rapidly
thereafter. The physical
examination is usually
not helpful, particularly
early in the course.
Subcutaneous emphysema
(crepitation) is an important
diagnostic finding but is not
very sensitive. A pleural
effusion with or without
a pneumothorax may be
present.
DIAGNOSIS
Giant bullae
• Patient's symptoms and
physical examination
may mimic those of a
pneumothorax. The patient
may also present with acute
dyspnoea due to another
cause (e.g., an exacerbation
of COPD).
•
•
•
disease, the diagnosis is
suggested by mediastinal
or free peritoneal air. Later,
there is widening of the
mediastinum, subcutaneous
emphysema, and pleural
effusion with or without
a pneumothorax. A CT
scan may demonstrate
oesophageal wall oedema
and thickening, extraoesophageal air, perioesophageal fluid with
or without gas bubbles,
mediastinal widening,
and air and fluid in the
pleural spaces and the
retroperitoneum.
The diagnosis can also be
confirmed by water-soluble
contrast oesophagram,
which reveals the location
and extent of extravasation
of contrast material.
A giant bulla is defined as
a bulla that occupies one
third or more of the ipsilateral
hemithorax and develops
slowly over time. However,
if there are no old x-rays
available for comparison,
then differentiation from
a pneumothorax may be
impossible. Faint radiopaque
lines within the bulla may
be the only clue that the
abnormality seen on
the chest x-ray is not a
pneumothorax.
Because placement of a
chest tube into a giant bulla
can have deleterious results,
a CT scan of the chest
should be obtained to help
make the differentiation
between both diagnoses.
Criteria
Size of pneumothorax[9]
26
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Pneumothorax
Diagnosis
Often, the postero-anterior (PA) chest x-ray is used to quantify the size of the pneumothorax. A
pneumothorax with a visible rim of 2 cm between the lung margin and the chest wall, when measured at the
level of the hilum, approximates a 50% pneumothorax by volume. The British Thoracic Society therefore
recommends the following as a gauge to the size of a pneumothorax:
• Small pneumothorax - a visible rim of ≤2 cm between the lung margin and the chest wall at the level of
the hilum on PA chest x-ray.
• Large pneumothorax - a visible rim >2 cm between the lung margin and the chest wall at the level of
the hilum on PA chest x-ray.
The choice of a 2 cm pneumothorax as the determinant of a small versus a large pneumothorax is a
compromise between the theoretical risk of needle puncture of the lung with a smaller pneumothorax and the
significant volume and length of time for spontaneous resolution of a larger pneumothorax.
Unfortunately lung collapse is not always uniform, particularly in patients with diseased lungs. Thus, it is
more difficult to estimate the size of these localised pneumothoraces. While CT scanning can be utilised as a
means to estimate the size of a pneumothorax, not all facilities purchase the software necessary to make this
assessment.
DIAGNOSIS
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27
Pneumothorax
Management
Recommendations
Urgent
Put out an immediate cardiac arrest call for any patient with suspected tension pneumothorax
and give high-flow ox ygen. Immediate decompression is required; do not wait for imaging results to
confirm the diagnosis.[9]
• Unless the tension pneumothorax is secondary to trauma, insert a large-bore cannula into the
pleural space through the second intercostal space in the mid-clavicular line or the fourth or fifth
intercostal space in the mid-axillary line. A ‘hiss’ of air confirms the diagnosis.[39] [9] [46]
• Use a standard safety cannula. Do not use a blood control (closed system) cannula for
tension pneumothorax decompression. [NHS England. National Patient Safety Alert – Blood
control safety cannula and needle thoracostomy for tension pneumothorax. Apr 2020]
• Insert a chest drain immediately after needle decompression.[9] Only insert a chest drain
yourself if you have had adequate training and are appropriately supervised.[70]
• If the tension pneumothorax is secondary to trauma, use open thoracostomy for decompression if
the expertise is available.[46]
MANAGEMENT
• The Advanced Trauma Life Support guideline now recommends using the fourth or fifth
intercostal space in the mid-axillary line as first-line if needle decompression is required.[71]
28
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Management
Pneumothorax
Key Recommendations
MANAGEMENT
Management of spontaneous pneumothorax. CXR = chest x-ray.
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29
Pneumothorax
Management
Manage pneumothorax according to the type (e.g., primary, secondary, traumatic) and size of the
pneumothorax, as well as the clinical status of the patient. Refer the patient to the respiratory team
within 24 hours if they are being admitted.[9] [10] [46]
• Attempt aspiration in patients with primary spontaneous pneumothorax (PSP) who require
intervention. If this fails, insert a chest drain.[9]
• A patient with a small PSP (or large PSP with minimal symptoms and normal observations)
can usually be managed conservatively.[9]
• Give high-flow oxygen and target oxygen saturations of close to 100% for all patients who are
being admitted for observation who have not had a chest drain inserted, unless they are at risk of
hypercapnic (type II) respiratory failure.[41]
• Give supplemental oxygen to all other patients if required to maintain oxygen saturations of
94% to 98% (or 88% to 92% if they are at risk of hypercapnic [type II] respiratory failure).[41]
• Surgery may be considered in certain patients to:[9]
• Repair a persistent air leak
• Prevent recurrence.
• If considering discharge, ensure the patient has adequate follow-up and give them verbal and
written information to return if they develop further breathlessness, as well as lifestyle advice to
prevent recurrence.[9]
Full Recommendations
Initial management
Give high-flow ox ygen and target oxygen saturations of close to 100% in all patients (unless they are at
risk of hypercapnic [type II] respiratory failure) with:[9] [41]
• Tension pneumothorax
• Pneumothorax that requires admission for observation without insertion of a chest drain.
Give supplemental oxygen to all other patients if required to maintain oxygen saturations of 94% to 98%
(or 88% to 92% if they are at risk of hypercapnic [type II] respiratory failure).[41]
MANAGEMENT
Guidelines on oxygen therapy often recommend an upper target saturation of 96%. However,
pneumothorax is a specific scenario where higher target oxygen saturations are advised; once there is
clinico-radiological evidence of resolution of a pneumothorax, supplemental oxygen should not be needed
unless there is underlying lung pathology such as COPD, asthma, or pneumonia.[41] [72]
30
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Management
Pneumothorax
Evidence: High-flow ox ygen
It is widely accepted that oxygen therapy increases the resolution rate of spontaneous
pneumothorax; however, studies were based on small populations. [73] [74] [75]
One small case series study examined the rate of resolution of pneumothorax in 8 patients who
received room air or high concentration oxygen delivered by a partial rebreathing mask.[74]
• Compared with a rate of resolution of 1.25% per day when the patients breathed room air, the
rate increased to 4.2% per day when breathing a high concentration of inspired oxygen.
In a larger study, the rate of absorption was measured in 12 patients breathing air (group 1), and in 10
patients during periods breathing air and other periods breathing oxygen at 6 L/minute (group 2).[73]
•
2
While breathing air, the mean rate of absorption in group 2 (4.8 cm /24 hours) was similar to
that in group 1.
• While breathing oxygen, however, the rate of absorption in group 2 increased to a mean of 17.9
2
cm /24 hours (P <0.01).
• The calculated time for full re-expansion for the patients in group 2 varied from 8 to 45 days
(mean 22.5 days) with continuous inhalation of air, and from 3 to 8 days (mean 5.4 days) with
daily oxygen therapy.
Other authors have highlighted the need to consider potential adverse effects of oxygen.[75]
The use of high concentration oxygen can shorten the duration of treatment before pneumothorax
resolution.[73] [74]
Tension pneumothorax
Put out an immediate cardiac arrest call for any patient with suspected tension pneumothorax and give
high-flow ox ygen. Immediate decompression is required; do not wait for confirmation of the tension
pneumothorax on imaging.[9]
• If the tension pneumothorax is not secondary to trauma, insert a large-bore cannula into the pleural
space through the second intercostal space in the mid-clavicular line or the fourth or fifth intercostal
space in the mid-axillary line. A ‘hiss’ of air confirms the diagnosis.[39] [9] [46]
• Use a standard safety cannula. Do not use a blood control (closed system) cannula for
tension pneumothorax decompression. [NHS England. National Patient Safety Alert – Blood
control safety cannula and needle thoracostomy for tension pneumothorax. Apr 2020]
• Insert a chest drain immediately after needle decompression.[9] [70]
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31
MANAGEMENT
• If the tension pneumothorax is secondary to trauma, use open thoracostomy for decompression if
the expertise is available.[46]
Pneumothorax
Management
• The Advanced Trauma Life Support guideline now recommends using the fourth or fifth
intercostal space in the mid-axillary line as first-line if needle decompression is required.[71]
Practical tip
A standard cannula for needle decompression may be too short if used in the second intercostal
space, mid-clavicular line, in some patients. The chest wall may be less deep in the fourth or fifth
intercostal space, mid-axillary line, and therefore this site is an alternative for decompression; it can
also be used as a site for chest drain insertion if there is initial failure with needle decompression.
However, the reverse may be true in practice for patients with a high body mass index.[9]
Bilateral pneumothorax
Insert a chest drain; start with the larger of the two pneumothoraces and involve senior support.[9]
Spontaneous pneumothorax
Manage spontaneous pneumothorax according to the type (primary or secondary) and size of the
pneumothorax, as well as the clinical status of the patient.[9]
Practical tip
The distinction between primary and secondary spontaneous pneumothorax is becoming
increasingly blurred in practice. Seek senior or specialist advice if you are in any doubt about which
type of pneumothorax your patient has.
MANAGEMENT
• In theory, a patient with any underlying respiratory diagnosis should be considered to have
a secondary, rather than primary, spontaneous pneumothorax. Most cases of secondary
spontaneous pneumothorax are in patients with COPD.[3]
• However, in practice, a patient with a history of only very mild respiratory disease might
be managed as a primary spontaneous pneumothorax - for example, a patient with mild,
intermittent asthma with no exacerbation of symptoms at presentation with the pneumothorax.
32
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Management
Pneumothorax
Management of spontaneous pneumothorax. CXR = chest x-ray.
A large pneumothorax is defined as having a visible rim >2 cm, whereas a small pneumothorax is defined
as having a visible rim ≤2 cm.[9]
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33
MANAGEMENT
Published with permission from the British Thoracic Society. Created by the BMJ Knowledge Centre.
Management
Pneumothorax
Attempt aspiration first-line in patients with a large primary pneumothorax (and insert a chest
drain if this fails), but consider conservative management if patients are asymptomatic with normal
observations.[79]
• Do not reattempt needle aspiration if your first attempt fails unless there were technical
difficulties.[9]
• Consider ambulatory devices, such as a Heimlich one-way valve, as an alternative initial
management for any stable patient with a primary pneumothorax.[80]
9
Correct clotting abnormalities (INR ≥1.5 and platelets ≤50 x 10 /L) before inserting a chest drain in
patients who are not critically unwell.[9] [53]
Insert a chest drain in all patients with a large secondary pneumothorax, regardless of the presence
of breathlessness. This includes patients who are >50 years with a significant smoking history.[70]
Practical tip
Obtain written consent prior to insertion of a chest drain, unless the patient is critically unwell.[70]
Ensure adequate analgesia prior to chest drain insertion in stable patients and use plenty of local
anaesthetic during insertion as it is a very painful procedure.[42]
A small-bore chest drain (≤14F) is generally recommended for spontaneous pneumothorax in nonventilated patients.[70]
The patient is usually positioned at 45° to 60° with their ipsilateral arm above their head. However,
for a traumatic pneumothorax, the chest drain is normally inserted while the patient is supine.[70]
The drain should be inserted aseptically; the Seldinger technique is most commonly used.[70]
Following insertion of a chest drain it is essential to: [87]
MANAGEMENT
• Check the underwater seal oscillates during respiration
• Order a repeat chest x-ray to confirm the position of the drain and the degree of lung re-expansion,
and to exclude any complications.
• Advise the patient to keep the underwater bottle upright and below the drain insertion site.
• Ensure regular analgesia is prescribed while the chest drain is in place.
34
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Pneumothorax
Management
Debate: Needle aspiration versus chest drain
Evidence supports the use of needle aspiration as an option for primary spontaneous
pneumothorax although recommendations in guidelines from different organisations on this
issue vary.
• The 2010 British Thoracic Society guidelines suggest that needle aspiration is an alternative to
insertion of a chest drain in some situations (see flow diagram above).[9]
• These guidelines differ from the earlier 2001 US guidelines, where the overall consensus was
that simple aspiration would rarely be appropriate.[38]
• Advantages of needle aspiration are that it is less painful than a chest drain and it reduces the
length of hospital stay.[9] [88]
• Disadvantages of needle aspiration are that it has a failure rate of around 30%, requiring a
second procedure (insertion of a chest drain, not a second needle aspiration), whereas insertion
of a small-bore chest drain (<14F) may be simpler.[9]
• The choice should take into account clinician experience and patient preference.[9]
A 2017 Cochrane systematic review, including 6 studies involving a total of 435 participants, compared
the efficacy and safety of aspiration versus intercostal tube drainage for the management of primary
spontaneous pneumothorax >20%.[89]
• Intercostal tube drainage had a higher immediate success rate (71.4%) versus aspiration
(58.2%) (P=0.0001; moderate-quality evidence assessed using GRADE).
• Patients treated with aspiration had a shorter duration of hospital stay (mean difference: ‐1.66
days, 95% CI ‐2.28 to ‐1.04; P <0.00001; moderate-quality evidence assessed using GRADE).
• Needle aspiration was associated with less pain (low-quality evidence assessed using GRADE).
A randomised controlled trial found shorter hospital stays when needle aspirations were used
compared with immediate chest tube drainage in patients with primary pneumothorax >30% or
secondary pneumothorax >20%.[90]
• 127 patients with a primary pneumothorax >30% or secondary pneumothorax >20% received
one or two needle aspirations (with a chest drain if the aspiration failed) or immediate treatment
with a chest drain.
• Overall, the hospital stay was shorter in the needle aspiration group (median 2.4 days
[interquartile range 1.2 to 4.7] vs. 4.6 days [2.3 to 7.8], P <0.001).
• This pattern was similar when patients with primary and secondary pneumothoraces were
analysed separately (primary: 2.2 days [1.2 to 4.5] vs. 4.1 days [2.2 to 5.9, P=0.008; secondary:
2.5 days [1.2 to 7.8] vs. 5.5 days [3.7 to 9.2], P=0.049).
MANAGEMENT
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35
Pneumothorax
Management
Evidence: Size of chest drain for drainage of pneumothorax
Guidelines suggest that small-bore chest drains (≤14F) are sufficient, mainly based on
evidence from several case series. [38] [9]
• For spontaneous pneumothorax, one small retrospective comparative study involving 67
patients found no difference in treatment success between large-bore (20F) and small-bore (9F)
chest drains.[91] [92]
• For uncomplicated traumatic pneumothorax, a randomised controlled trial involving 40 patients
compared 14 F pigtail catheters and 28 F chest drains and found that pigtail catheters were
associated with less pain, while the duration of drain insertion, success rate, and insertionrelated complications were similar between the groups.[93]
Small-bore chest tubes appear to be as effective as larger-bore tubes for the treatment of
spontaneous or traumatic pneumothorax, and are associated with less pain. [91] [93] [92]
Traumatic (non-tension) pneumothorax
Traumatic pneumothorax should be managed by a thoracic surgeon; management will depend on
the size of the pneumothorax and the clinical status of the patient. This may include a chest drain or
thoracotomy.[14]
• Never leave a patient with a penetrating chest wound or open pneumothorax
unat tended as tension pneumothorax may develop. Cover the wound with a simple occlusive
dressing and observe closely.[42] [46]
• Give a dose of prophylactic antibiotics if a chest drain is being inserted to decrease the risk of
empyema and pneumonia.[94] Check local protocols.
Management in hospital
Refer all patients who are being admitted to the respiratory team within 24 hours of admission.[9]
• Chest drain management is best delivered by nurses with specialist expertise.
• Observe the patient for at least 24 hours if they require admission but do not need a chest drain.
Monitor for complications of chest drain insertion. Visceral injury is the most serious complication, but
other more common complications include:[9]
MANAGEMENT
• Pain
• Intrapleural or wound infection
• Drain dislodgement or blockage
• Surgical emphysema.
Consider negative pressure suction (high-volume low-pressure systems) if there is a persistent air leak
(i.e., the chest drain continues to bubble) for ≥48 hours.[9]
36
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Management
Pneumothorax
Practical tip
Use of suction too early after chest drain insertion may cause re-expansion pulmonary oedema,
especially in the case of a primary spontaneous pneumothorax that may have been present for
more than a few days.[9]
Order a chest x-ray if the chest drain stops bubbling to determine whether this is due to blockage or
malpositioning of the drain or resolution of the pneumothorax.[87]
• If the drain has stopped bubbling but is still swinging, this implies resolution of the pneumothorax
with a patent drain.
• If the drain is not swinging or bubbling, the drain may be blocked. Try flushing the drain as this
may clear the blockage.
Evidence: Chest drain management
There is insufficient evidence and differences of opinion on the use of suction, whether the
chest drain should be clamped prior to removal, and, if it is clamped, the appropriate duration.
[38] [80]
• Chest drains should be removed only when there is a re-expansion of the lung and no clinical
evidence of an air leak.[38]
• An occult air leak, not observed clinically, may lead to the recurrence of pneumothorax, so some
clinicians clamp the chest tube before removal.[95]
• However, clamping of a chest drain prior to removal is now not common practice in many
hospitals in the UK. As a greater understanding of the use of air leak measurement is
developed, it is likely that the process of clamping will stop completely. Of the expert panel
involved in developing the US guidelines on management of spontaneous pneumothorax, it was
reported that around half would never clamp a chest tube while the other half of panel members
would clamp the tube approximately 4 hours after the last evidence of an air leak.[38]
• One reason given is that clamping requires close monitoring of the patient and delays
chest drain removal.[70]
• In a small randomised controlled trial involving 41 patients with spontaneous
pneumothorax, a clamping time of 6 hours was compared with 24 hours and no difference
was found in the risk of recurrence at 7 days.[96]
• However, some authors suggest that clamping the chest drain allows for more definitive
assessment of persistent occult air leaks, so avoiding premature removal.[97]
Persistent air leaks can be managed using a chest drain with an underwater seal connected to suction,
although a systematic review found little evidence for the use of suction.[80]
MANAGEMENT
• Air leak measurement may predict chest drain failure, with higher rates of air flow through a
chest drain associated with greater failure rates of treatment.[98]
Only remove a chest drain based on senior or specialist advice. The decision is based on the
clinical status of the patient and resolution of the pneumothorax, or if the drain is blocked.[87] [70]
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37
Pneumothorax
Management
• Prepare for removal of a chest drain by ensuring any drain on suction is placed on 'water seal' and
remove any sutures or dressings that are holding it in place.
• Remove the drain quickly at the end of expiration during a Valsalva manoeuvre and place a sterile
dressing immediately over the insertion site.
• Cover the insertion site with an occlusive dressing. Only suture the insertion site if a large-bore
(≥18F) drain has been used.
• Order a chest x-ray to ensure the lung remains fully re-expanded. This is normally performed
several hours after chest drain removal.
Surgery
Discuss all patients with a thoracic surgeon early (within 3-5 days) who meet the following criteria:[9]
• Persistent air leak
• Failure of the lung to re-expand.
Also seek advice from a thoracic surgeon for patients with:[9]
• Second ipsilateral pneumothorax
• First contralateral pneumothorax
• Synchronous bilateral spontaneous pneumothorax
• Spontaneous haemothorax
• Profession at risk (e.g., pilots, divers)
• Pregnancy.
The main aims of surgery are to repair a persistent air leak and prevent recurrence.[9]
Options include open thoracotomy or video-assisted thoracoscopic surgery (VATS).[9]
Practical tip
MANAGEMENT
Most air leaks will resolve spontaneously if managed conservatively for as long as 14 days.[9]
38
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Management
Pneumothorax
Evidence: Open thoracotomy versus VATS
Evidence comparing surgical treatment for pneumothorax (comprising open thoracotomy with
pleural abrasion or pleurectomy) versus video-assisted thoracic surgery (VATS) shows a tradeoff between risks and benefits of the two approaches. [99] [9]
• A systematic review including 29 studies (4 randomised and 25 non-randomised) of VATS
versus open surgery for pneumothorax found:[100]
• The recurrence rate was around 4 times higher with the VATS procedure.
• An earlier systematic review including 4 randomised controlled trials (RCTs) of VATS versus
thoracotomy among patients with pneumothorax found that:[101]
• VATS was associated with shorter length of hospital stay (1 to 4.2 days in the 3 RCTs
reporting this outcome; significantly different in 2 of the 3 RCTs).
• All 4 RCTs reported less use of analgesics with VATS than thoracotomy (significantly
different in 3 of the 4 RCTs).
• 2 RCTs reported similar complication rates between the groups and 2 did not report
complications.
The British Thoracic Society guideline on spontaneous pneumothorax suggests that the potential
benefits of the less invasive VATS approach should be weighed against the increased risk of
recurrence (from around 1% to around 5%).[9]
If the patient has a secondary spontaneous pneumothorax and a persistent air leak, but is unable or
unwilling to undergo surgery, options include:[9]
• Chemical pleurodesis. This should only be performed by a respiratory specialist.
• Ambulatory management with a Heimlich one-way valve.[80]
MANAGEMENT
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39
Pneumothorax
Management
Evidence: Management of persistent air leak in patients who are unsuitable for surgery
There is a lack of expert consensus regarding management of persistent air leaks in patients in
whom surgery is contraindicated. [102]
The British Thoracic Society guideline on spontaneous pneumothorax recommends
using a Heimlich valve or medical pleurodesis as options for patients with secondary
spontaneous pneumothorax who are unfit for surgery but have persistent air leaks. [9]
• Patients with secondary spontaneous pneumothorax are more likely both to have persistent air
leaks and to be unfit for surgery due to their underlying lung disease.[9]
• Management of such patients requires liaison between medical and surgical teams.[9]
One conservative option is the use of a Heimlich one-way flut ter valve.[103] [102]
• The valve is attached to the chest drain and allows air to escape from the pneumothorax when
the patient exhales, but closes off during inspiration so air cannot pass back into the chest
drain.[103] [102]
• Advantages of the Heimlich valve over the water seal drain are its small size (<13 cm) and
portability, which allow the patient to mobilise and even be discharged from hospital, even when
treatment is prolonged.[103]
An alternative option is the use of medical pleurodesis (i.e., without surgical
intervention). [102]
• This is the use of chemicals (e.g., talc, various tetracyclines) in the pleural space that cause
an inflammatory response and lead to adhesion between the two pleural layers (visceral and
parietal).[102]
• The technique has been reported as successful in randomised controlled trials and several case
series.[104] [105] [102]
• Potential complications include chest pain, fever, acute lung injury, and empyema (occurring in
around 1% of patients).[102]
• There is limited evidence for use of blood pleurodesis for patients who are not suitable
for surgery. However, it may be used in patients where talc pleurodesis has failed, prompt
resolution of the pneumothorax is needed, or pneumothorax is present with acute respiratory
distress syndrome.[106]
A systematic review assessed various chemicals in medical pleurodesis for spontaneous
pneumothorax and found few randomised prospective comparison studies, limiting the
ability to make firm recommendations. [107]
MANAGEMENT
• It included 50 studies, involving patients with first or recurrent pneumothorax or ongoing air leak,
treated with chemicals via chest drains, at thoracoscopy or during surgery.
• Overall, the findings indicated that many chemicals have been used and that chemical
pleurodesis appears to be effective at preventing recurrence of pneumothorax in selected
patients when used in combination with surgery or thoracoscopy. However, the evidence is
limited due to the lack of randomised prospective comparison studies.
40
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Pneumothorax
Management
Special cases
Catamenial pneumothorax
Management includes a combination of surgical intervention and hormonal manipulation to suppress
ovulation and menstruation.[108] [9]
Pneumothorax ex vacuo
Management depends on the underlying cause and should aim to alleviate the endobronchial obstruction.
For example, bronchoscopy may be used if the pneumothorax is secondary to endobronchial obstruction
with lobar or whole lung collapse.[109]
Chest drain is not generally recommended, especially in asymptomatic patients.[110]
HIV
Patients with HIV infection and pneumothorax require early insertion of a chest drain and surgical referral
as well as treatment for HIV and any associated Pneumocystis jiroveci infection.[9]
Cystic fibrosis
Patients with cystic fibrosis and pneumothorax require early discussion and aggressive treatment; discuss
all patients early with a surgeon.[9]
Discharge
It is common practice to consider discharge after a period of observation (usually 4-6 hours) without
admission in all patients with a primary pneumothorax who meet the following criteria:[9]
• Small pneumothorax and no breathlessness, OR
• Successful needle aspiration of a large pneumothorax with an improvement in breathing AND
• Normal observations (oxygen saturations >96%, respiratory rate <20, heart rate <100 and blood
pressure >100/60 mmHg).
Practical tip
All patients with spontaneous secondary pneumothorax require admission initially as clinical
symptoms tend to be more severe than a primary pneumothorax and they are more likely to have a
persistent air leak.[111] [9]
MANAGEMENT
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41
Management
Pneumothorax
Evidence: Conservative management
Evidence supports the view that patients with small primary spontaneous pneumothoraces
without treatment, and those with larger primary spontaneous pneumothoraces after
aspiration, may not need hospitalisation as the likelihood of complications is low. [112]
The British Thoracic Society guideline on spontaneous pneumothorax states that people without
breathlessness and a small primary spontaneous pneumothorax may be treated conservatively and
managed as outpatients, assuming they have ready access to medical care if required.[9]
• Underpinning evidence comes from retrospective cohort studies of patients treated
conservatively in single settings.[113] [114]
For larger primary spontaneous pneumothoraces after aspiration, outpatient treatment is possible in
many cases.[112]
• A Cochrane systematic review including 6 randomised controlled trials and a total of 435
patients with primary spontaneous pneumothoraces requiring drainage (either symptomatic or
>20%) compared simple aspiration with chest tube drainage.[89]
• Around 58% of the aspiration group achieved immediate (near) complete lung expansion
(6 studies; moderate-quality evidence as assessed using GRADE).
• Around 37% required admission after the procedure (3 studies; very low quality evidence
as assessed using GRADE).
• Fewer adverse events occurred when patients were treated by simple aspiration than by
tube drainage, including less perceived pain and lower pain scores, reduced need for
thoracoscopic pleurodesis, and fewer technical adverse events. The authors add that
this information should be viewed with caution due to the low quality of evidence for this
outcome.
The conservative approach and outpatient treatment may be appropriate in patients with primary
spontaneous pneumothorax who can easily return to medical care if their symptoms deteriorate.[9]
MANAGEMENT
Give all patients the following written and verbal advice prior to discharge:[9]
• They should return as an emergency if they develop further breathlessness
• They can return to work and can resume normal physical activity once symptoms have resolved,
unless they have a high-risk occupation (e.g., airline pilot)
• They should not dive unless a definitive prevention strategy has been performed such as surgical
pleurectomy
• They should avoid air travel until 1 week post full resolution of the pneumothorax; resolution must
be confirmed on chest x-ray
• They should be given smoking cessation advice; risk of pneumothorax recurrence for people who
smoke in the first year is as high as 32%. Smoking cessation reduces this risk fourfold.[10]
Ensure there is adequate follow-up.
• All patients require follow-up with a respiratory physician to:[9]
42
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Management
Pneumothorax
• Ensure full resolution of the pneumothorax
• Give optimal care of any underlying lung disease
• Explain the risk of recurrence and need for possible surgical intervention
• Reinforce lifestyle advice on issues such as smoking and air travel.
• Organise a follow-up chest x-ray after 2 to 4 weeks to monitor resolution of the pneumothorax for all
patients who were managed with observation alone or by needle aspiration.[9]
Procedural videos
Treatment algorithm overview
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Initial
( summary )
suspected tension pneumothorax
1st
immediate decompression
plus
high-flow ox ygen
plus
chest drain + hospital admission
MANAGEMENT
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43
Pneumothorax
Management
Acute
( summary )
confirmed primary spontaneous
pneumothorax
breathless and/or large
pneumothorax (visible
rim >2 cm between the
lung margin and the chest
wall)
small pneumothorax
(visible rim ≤2 cm
between the lung margin
and the chest wall)
1st
percutaneous aspiration
consider
chest drain + hospital admission
consider
supplemental ox ygen
consider
surgery
1st
observation ± supplemental ox ygen
1st
chest drain + hospital admission
confirmed secondary spontaneous
pneumothorax
breathless or large
pneumothorax (visible
rim >2 cm between the
lung margin and the chest
wall)
moderate pneumothorax
(visible rim 1-2 cm
between the lung margin
and the chest wall)
small pneumothorax
(visible rim <1 cm
between the lung margin
and the chest wall)
consider
supplemental ox ygen
consider
surgery or pleurodesis
1st
percutaneous aspiration ± high-flow
ox ygen
consider
chest drain + hospital admission ±
supplemental ox ygen
1st
high-flow ox ygen + observation + hospital
admission
1st
high-flow ox ygen + observation + refer to
thoracic surgeon
1st
high-flow ox ygen
consider
bronchoscopy
MANAGEMENT
confirmed traumatic non-tension
pneumothorax
confirmed pneumothorax ex vacuo
44
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Pneumothorax
Management
Ongoing
( summary )
acute pneumothorax resolved
1st
prevention of recurrence
MANAGEMENT
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45
Management
Pneumothorax
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Initial
suspected tension pneumothorax
1st
immediate decompression
» Put out an immediate cardiac arrest call.
» Immediate decompression is required; do
not wait for imaging results to confirm the
diagnosis.[9]
• Unless the tension pneumothorax is
secondary to trauma, insert a large-bore
cannula into the pleural space through
the second intercostal space in the
mid-clavicular line or the fourth or fifth
intercostal space in the mid-axillary line. A
‘hiss’ of air confirms the diagnosis.[39] [9]
[46]
• If the tension pneumothorax is
secondary to trauma, use open
thoracostomy for decompression if the
expertise is available.[46]
• The Advanced Trauma Life Support
guideline now recommends using
the fourth or fifth intercostal space
in the mid-axillary line as firstline if needle decompression is
required.[71]
»
plus
high-flow ox ygen
Treatment recommended for ALL patients in
selected patient group
» Give high-flow ox ygen and target oxygen
saturations of close to 100% (unless patients
are at risk of hypercapnic [type II] respiratory
failure).[9] [41]
MANAGEMENT
» Guidelines on oxygen therapy often
recommend an upper target saturation of 96%.
However, pneumothorax is a specific scenario
where higher target oxygen saturations are
advised; once there is clinico-radiological
evidence of resolution of a pneumothorax,
supplemental oxygen should not be needed
unless there is underlying lung pathology such
as COPD, asthma, or pneumonia.[41] [72]
46
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Management
Pneumothorax
Initial
plus
chest drain + hospital admission
Treatment recommended for ALL patients in
selected patient group
Primary options
» ibuprofen: 300-600 mg orally (immediaterelease) every 6-8 hours when required,
maximum 2400 mg/day
-and/or» codeine phosphate: 30-60 mg orally/
intramuscularly every 4 hours when required,
maximum 240 mg/day
Secondary options
» morphine sulfate: 5-10 mg orally
(immediate-release)/subcutaneously/
intravenously/intramuscularly every 4 hours
initially, adjust dose according to response
-or» oxycodone: 5 mg orally (immediaterelease) every 4-6 hours initially, adjust dose
according to response, maximum 400 mg/
day; 1-10 mg intravenously every 4 hours
when required
» Insert a chest drain immediately after
decompression.[9]
» Only insert a chest drain if you have had
adequate training and are appropriately
supervised. [70]
• Obtain written consent, unless the patient
is critically unwell.
»
» Following insertion of a chest drain it is
essential to: [87]
• Check the underwater seal oscillates
during respiration
• Order a repeat chest x-ray to confirm
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47
MANAGEMENT
the position of the drain and degree of
lung re-expansion, and to exclude any
complications
• Advise the patient to keep the underwater
bottle upright and below the drain insertion
site
• Ensure regular analgesia is prescribed
while the chest drain is in place (e.g., a
non-steroidal anti-inflammatory drug such
Pneumothorax
Management
Initial
as ibuprofen and/or a weak opioid such as
codeine, escalating to a stronger opioid
such as morphine or oxycodone according
to response and local protocols).
MANAGEMENT
» Only remove a chest drain based on senior or
specialist advice.
48
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Management
Pneumothorax
Acute
confirmed primary spontaneous
pneumothorax
breathless and/or large
pneumothorax (visible
rim >2 cm between the
lung margin and the chest
wall)
1st
percutaneous aspiration
» Aspirate <2.5 L using a 16-18G cannula.
Do not reattempt needle aspiration if your
first attempt fails unless there were technical
difficulties.[9]
» If successful (visible rim ≤2 cm on chest x-ray
and breathing improved) it is common practice to
consider discharge after a period of observation
(usually 4-6 hours).[9]
» In some patients with a large primary
pneumothorax but minimal symptoms and
normal observations, conservative management
without aspiration may be appropriate.[9]
consider
chest drain + hospital admission
Treatment recommended for SOME patients in
selected patient group
Primary options
» ibuprofen: 300-600 mg orally (immediaterelease) every 6-8 hours when required,
maximum 2400 mg/day
-and/or» codeine phosphate: 30-60 mg orally/
intramuscularly every 4 hours when required,
maximum 240 mg/day
Secondary options
» morphine sulfate: 5-10 mg orally
(immediate-release)/subcutaneously/
intravenously/intramuscularly every 4 hours
initially, adjust dose according to response
-or» oxycodone: 5 mg orally (immediaterelease) every 4-6 hours initially, adjust dose
according to response, maximum 400 mg/
day; 1-10 mg intravenously every 4 hours
when required
» If aspiration is unsuccessful (visible rim >2 cm
on chest x-ray) insert chest drain and admit.
9
platelets ≤50 x 10 /L) before insertion of a
chest drain in patients who are not critically
unwell.[9] [53]
» Ensure adequate analgesia prior to chest drain
insertion in a stable patient and use plenty of
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49
MANAGEMENT
» Correct clotting abnormalities (INR ≥1.5 and
Management
Pneumothorax
Acute
local anaesthetic during insertion as it is a very
painful procedure (see below).[42]
» Only insert a chest drain if you have had
adequate training and are appropriately
supervised. [70]
• Obtain written consent, unless the patient
is critically unwell.
»
» Following insertion of a chest drain it is
essential to: [87]
• Check the underwater seal oscillates
during respiration
• Order a repeat chest x-ray to confirm
the position of the drain and degree of
lung re-expansion, and to exclude any
complications
• Advise the patient to keep the underwater
bottle upright and below the drain insertion
site
• Ensure regular analgesia is prescribed
while the chest drain is in place (e.g., a
non-steroidal anti-inflammatory drug such
as ibuprofen and/or a weak opioid such as
codeine, escalating to a stronger opioid
such as morphine or oxycodone according
to response and local protocols).
» Consider negative pressure suction (highvolume low-pressure systems) if there is a
persistent air leak (i.e., the chest drain continues
to bubble) for ≥48 hours.[9]
» Only remove a chest drain based on senior or
specialist advice.
» In some patients with a large primary
pneumothorax but minimal symptoms and
normal observations, conservative management
without a chest drain may be appropriate.[9]
consider
supplemental ox ygen
MANAGEMENT
Treatment recommended for SOME patients in
selected patient group
» Give supplemental oxygen if required to
maintain oxygen saturations of 94% to 98% (or
88% to 92% if patients are at risk of hypercapnic
[type II] respiratory failure).[41] Guidelines
50
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Management
Pneumothorax
Acute
on oxygen therapy often recommend an
upper target saturation of 96%. However,
pneumothorax is a specific scenario where
higher target oxygen saturations are advised;
once there is clinico-radiological evidence of
resolution of a pneumothorax, supplemental
oxygen should not be needed unless there
is underlying lung pathology such as COPD,
asthma, or pneumonia.[41] [72]
consider
surgery
Treatment recommended for SOME patients in
selected patient group
» Discuss all patients with a thoracic surgeon
early (within 3-5 days) who meet the following
criteria:[9]
• Persistent air leak
• Failure of the lung to re-expand.
» Options include open thoracotomy or videoassisted thoracoscopic surgery (VATS).[9]
small pneumothorax
(visible rim ≤2 cm
between the lung margin
and the chest wall)
1st
observation ± supplemental ox ygen
» It is common practice to consider discharge
after a period of observation (usually
4-6 hours) without admission in patients
with a small primary pneumothorax with no
breathlessness and with normal observations
(oxygen saturations >96%, respiratory rate <20,
heart rate <100, and blood pressure >100/60
mmHg).[9]
» Give supplemental oxygen if required to
maintain oxygen saturations of 94% to 98% (or
88% to 92% if patients are at risk of hypercapnic
[type II] respiratory failure).[41] Guidelines
on oxygen therapy often recommend an
upper target saturation of 96%. However,
pneumothorax is a specific scenario where
higher target oxygen saturations are advised;
once there is clinico-radiological evidence of
resolution of a pneumothorax, supplemental
oxygen should not be needed unless there
is underlying lung pathology such as COPD,
asthma, or pneumonia.[41] [72]
confirmed secondary spontaneous
pneumothorax
1st
MANAGEMENT
breathless or large
pneumothorax (visible
rim >2 cm between the
lung margin and the chest
wall)
chest drain + hospital admission
Primary options
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51
Management
Pneumothorax
Acute
» ibuprofen: 300-600 mg orally (immediaterelease) every 6-8 hours when required,
maximum 2400 mg/day
-and/or» codeine phosphate: 30-60 mg orally/
intramuscularly every 4 hours when required,
maximum 240 mg/day
Secondary options
» morphine sulfate: 5-10 mg orally
(immediate-release)/subcutaneously/
intravenously/intramuscularly every 4 hours
initially, adjust dose according to response
-or» oxycodone: 5 mg orally (immediaterelease) every 4-6 hours initially, adjust dose
according to response, maximum 400 mg/
day; 1-10 mg intravenously every 4 hours
when required
» Correct clotting abnormalities (INR ≥1.5 and
9
platelets ≤50 x 10 /L) before insertion of a
chest drain in patients who are not critically
unwell.[9] [53]
» Ensure adequate analgesia prior to chest drain
insertion in a stable patient and use plenty of
local anaesthetic during insertion as it is a very
painful procedure (see below).[42]
» Only insert a chest drain if you have had
adequate training and are appropriately
supervised. [70]
• Obtain written consent, unless the patient
is critically unwell.
»
» Following insertion of a chest drain it is
essential to: [87]
• Check the underwater seal oscillates
during respiration
• Order a repeat chest x-ray to confirm
MANAGEMENT
the position of the drain and degree of
lung re-expansion, and to exclude any
complications
• Advise the patient to keep the underwater
bottle upright and below the drain insertion
site
• Ensure regular analgesia is prescribed
while the chest drain is in place (e.g., a
52
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 22, 2024.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.
Management
Pneumothorax
Acute
non-steroidal anti-inflammatory drug such
as ibuprofen and/or a weak opioid such as
codeine, escalating to a stronger opioid
such as morphine or oxycodone according
to response and local protocols).
» Consider negative pressure suction (highvolume low-pressure systems) if there is a
persistent air leak (i.e., the chest drain continues
to bubble) for ≥48 hours.[9]
» Only remove a chest drain based on senior or
specialist advice.
consider
supplemental ox ygen
Treatment recommended for SOME patients in
selected patient group
» Give supplemental oxygen if required to
maintain oxygen saturations of 94% to 98% (or
88% to 92% if patients are at risk of hypercapnic
[type II] respiratory failure).[41] Guidelines
on oxygen therapy often recommend an
upper target saturation of 96%. However,
pneumothorax is a specific scenario where
higher target oxygen saturations are advised;
once there is clinico-radiological evidence of
resolution of a pneumothorax, supplemental
oxygen should not be needed unless there
is underlying lung pathology such as COPD,
asthma, or pneumonia.[41] [72]
consider
surgery or pleurodesis
Treatment recommended for SOME patients in
selected patient group
» Discuss all patients with a thoracic surgeon
early (within 3-5 days) who meet the following
criteria:[9]
• Persistent air leak
• Failure of the lung to re-expand.
» Options include open thoracotomy or videoassisted thoracoscopic surgery (VATS).[9]
» If the patient has a secondary spontaneous
pneumothorax, but is unable or unwilling to
undergo surgery, options include:[9]
MANAGEMENT
• Chemical pleurodesis. This should
only be performed by a respiratory
specialist.
• Ambulatory management with a
Heimlich one-way valve.[80]
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53
Management
Pneumothorax
Acute
moderate pneumothorax
(visible rim 1-2 cm
between the lung margin
and the chest wall)
1st
percutaneous aspiration ± high-flow
ox ygen
» Aspirate <2.5 L using a 16-18G cannula.[9]
» If successful (visible rim <1 cm on chest xray) give high-flow ox ygen and target oxygen
saturations of close to 100% (unless patients
are at risk of hypercapnic [type II] respiratory
failure).[9] [41]
» Guidelines on oxygen therapy often
recommend an upper target saturation of 96%.
However, pneumothorax is a specific scenario
where higher target oxygen saturations are
advised; once there is clinico-radiological
evidence of resolution of a pneumothorax,
supplemental oxygen should not be needed
unless there is underlying lung pathology such
as COPD, asthma, or pneumonia.[41] [72]
» Admit and observe for at least 24 hours.[9] [41]
» Do not reat tempt needle aspiration if your
first attempt fails, unless there were technical
difficulties.[9]
consider
chest drain + hospital admission ±
supplemental ox ygen
Treatment recommended for SOME patients in
selected patient group
Primary options
» ibuprofen: 300-600 mg orally (immediaterelease) every 6-8 hours when required,
maximum 2400 mg/day
-and/or» codeine phosphate: 30-60 mg orally/
intramuscularly every 4 hours when required,
maximum 240 mg/day
Secondary options
MANAGEMENT
» morphine sulfate: 5-10 mg orally
(immediate-release)/subcutaneously/
intravenously/intramuscularly every 4 hours
initially, adjust dose according to response
-or» oxycodone: 5 mg orally (immediaterelease) every 4-6 hours initially, adjust dose
according to response, maximum 400 mg/
day; 1-10 mg intravenously every 4 hours
when required
» If aspiration is unsuccessful (visible rim >2
cm on chest x-ray) insert chest drain and admit.
Give supplemental oxygen if required to maintain
54
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BMJ Best Practice topics are regularly updated and the most recent version
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subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.
Management
Pneumothorax
Acute
oxygen saturations of 94% to 98% (or 88% to
92% if patients are at risk of hypercapnic [type
II] respiratory failure).[41] Guidelines on oxygen
therapy often recommend an upper target
saturation of 96%. However, pneumothorax
is a specific scenario where higher target
oxygen saturations are advised; once there
is clinico-radiological evidence of resolution
of a pneumothorax, supplemental oxygen
should not be needed unless there is underlying
lung pathology such as COPD, asthma, or
pneumonia.[41] [72]
» Correct clotting abnormalities (INR ≥1.5 and
9
platelets ≤50 x 10 /L) before insertion of a
chest drain in patients who are not critically
unwell.[9] [53]
» Ensure adequate analgesia prior to chest drain
insertion in a stable patient and use plenty of
local anaesthetic during insertion as it is a very
painful procedure (see below).[42]
» Only insert a chest drain if you have had
adequate training and are appropriately
supervised. [70]
• Obtain written consent, unless the patient
is critically unwell.
»
» Following insertion of a chest drain it is
essential to: [87]
• Check the underwater seal oscillates
during respiration
• Order a repeat chest x-ray to confirm
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BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
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55
MANAGEMENT
the position of the drain and degree of
lung re-expansion, and to exclude any
complications
• Advise the patient to keep the underwater
bottle upright and below the drain insertion
site
• Ensure regular analgesia is prescribed
while the chest drain is in place (e.g., a
non-steroidal anti-inflammatory drug such
as ibuprofen and/or a weak opioid such as
codeine, escalating to a stronger opioid
such as morphine or oxycodone according
to response and local protocols).
Management
Pneumothorax
Acute
» Only remove a chest drain based on senior or
specialist advice.
small pneumothorax
(visible rim <1 cm
between the lung margin
and the chest wall)
1st
high-flow ox ygen + observation + hospital
admission
» Give high-flow ox ygen and target oxygen
saturations of close to 100% (unless patients
are at risk of hypercapnic [type II] respiratory
failure).[9] [41]
» Guidelines on oxygen therapy often
recommend an upper target saturation of 96%.
However, pneumothorax is a specific scenario
where higher target oxygen saturations are
advised; once there is clinico-radiological
evidence of resolution of a pneumothorax,
supplemental oxygen should not be needed
unless there is underlying lung pathology such
as COPD, asthma, or pneumonia.[41] [72]
» Admit and observe for at least 24 hours.[9] [41]
confirmed traumatic non-tension
pneumothorax
1st
high-flow ox ygen + observation + refer to
thoracic surgeon
» Give high-flow ox ygen and target oxygen
saturations of close to 100% (unless at risk
of hypercapnic [type II] respiratory failure)
in patients with pneumothorax that requires
admission for observation without drainage.[9]
[41]
» Give supplemental oxygen to all other patients
if required to maintain oxygen saturations of
94% to 98% (or 88% to 92% if they are at risk
of hypercapnic [type II] respiratory failure).[41]
Guidelines on oxygen therapy often recommend
an upper target saturation of 96%. However,
pneumothorax is a specific scenario where
higher target oxygen saturations are advised;
once there is clinico-radiological evidence of
resolution of a pneumothorax, supplemental
oxygen should not be needed unless there
is underlying lung pathology such as COPD,
asthma, or pneumonia.[41] [72]
MANAGEMENT
» Further management should be decided by a
thoracic surgeon; this will depend on the size
of the pneumothorax and the clinical status of
the patient. This may include a chest drain or
thoracotomy.[14]
» Do not aspirate a traumatic
pneumothorax.
56
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Management
Pneumothorax
Acute
» Never leave a patient with a penetrating
chest wound or open pneumothorax
unat tended as tension pneumothorax may
develop. Cover the wound with a simple
occlusive dressing and observe closely.[42] [46]
» Give a dose of prophylactic antibiotics if a
chest drain is being inserted to decrease the
risk of empyema and pneumonia. Check local
protocols.[94]
confirmed pneumothorax ex vacuo
1st
high-flow ox ygen
» Give high-flow ox ygen and target oxygen
saturations of close to 100% (unless at risk
of hypercapnic [type II] respiratory failure)
in patients with pneumothorax that requires
admission for observation without drainage or
aspiration.[9] [41]
» Give supplemental oxygen to all other patients
if required to maintain oxygen saturations of
94% to 98% (or 88% to 92% if they are at risk
of hypercapnic [type II] respiratory failure).[41]
Guidelines on oxygen therapy often recommend
an upper target saturation of 96%. However,
pneumothorax is a specific scenario where
higher target oxygen saturations are advised;
once there is clinico-radiological evidence of
resolution of a pneumothorax, supplemental
oxygen should not be needed unless there
is underlying lung pathology such as COPD,
asthma, or pneumonia.[41] [72]
consider
bronchoscopy
Treatment recommended for SOME patients in
selected patient group
» Bronchoscopy may be used if the
pneumothorax is secondary to endobronchial
obstruction with lobar or whole lung
collapse.[109]
MANAGEMENT
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57
Management
Pneumothorax
Ongoing
acute pneumothorax resolved
1st
prevention of recurrence
» Give patients the following advice prior to
discharge:[9]
• They should not dive unless a definitive
prevention strategy has been performed,
such as surgical pleurectomy
• They should avoid air travel until 1 week
post full resolution of the pneumothorax;
resolution must be confirmed on chest xray
• They should be given smoking cessation
advice; risk of pneumothorax recurrence
for people who smoke in the first year
is as high as 32%. Smoking cessation
reduces this risk fourfold.
» Patients may need surgical intervention
to prevent recurrence; options include open
thoracotomy or video-assisted thoracoscopic
surgery (VATS). Indications for discussion with a
thoracic surgeon are:[9]
• Second ipsilateral pneumothorax
• First contralateral pneumothorax
• Synchronous bilateral spontaneous
pneumothorax
• Spontaneous haemothorax
• Professions at risk (e.g., pilots, divers)
• Pregnancy.
» Other prevention strategies may include
targeting the underlying cause such as:
MANAGEMENT
• Hormonal manipulation to suppress
ovulation and menstruation for patients
with catamenial pneumothorax[108] [9]
• Treatment for HIV and any associated
pneumocystis jiroveci infection for patients
with HIV[9]
• Early discussion with a surgeon for
patients with cystic fibrosis.[9]
58
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Pneumothorax
Management
Emerging
Endobronchial valves
Endobronchial valves are emerging as an effective treatment for a persistent air leak, if other interventions
(e.g., surgery, pleurodesis) are contraindicated or have failed. They are not yet in widespread use,
however.[120]
Primary prevention
Cigarette smoking cessation is the single most important preventative measure for both primary and
secondary spontaneous pneumothoraces.[38]
Secondary prevention
Early recognition and treatment of respiratory infections, such as tuberculosis and Pneumocystis jirovecii
respiratory infection in AIDS, are important measures in the prevention of pneumothoraces. Adherence to
prescribed therapy may curb the risk of a secondary spontaneous pneumothorax in those patients. Smoking
cessation is the single most important step to reduce the risk of a pneumothorax recurrence.
Surgery may be indicated for some patients to prevent recurrence. Options include open thoracotomy or
video-assisted thoracoscopic surgery (VATS).[9]
Patient discussions
Patients with a primary spontaneous pneumothorax should understand that they are at risk of ipsilateral
and contralateral pneumothoraces in the future. They should also be made aware that each recurrence
increases their risk for subsequent ipsilateral pneumothoraces and that pleurodesis treatment can
fail. These patients should, therefore, be instructed to seek immediate medical evaluation should their
symptoms recur.
Patients with a secondary spontaneous pneumothorax should be advised that each recurrence increases
their risk for subsequent ipsilateral pneumothoraces. Patients should also be made aware that their
underlying lung disease may result in a contralateral pneumothorax and that pleurodesis treatment can
fail. Patients should be instructed to seek immediate medical attention should their symptoms recur.
Advise smoking cessation. Risk of pneumothorax recurrence for people who smoke in the first year is as
high as 32%. Smoking cessation reduces this risk fourfold.[10]
Patients can return to work and can resume normal physical activity once symptoms have resolved,
unless they have a high-risk occupation (e.g., airline pilot).[9]
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59
MANAGEMENT
Patients should be counselled regarding the dangers of sudden barometric pressure changes that might
occur with high-altitude activity or underwater diving. Patients who have had a pneumothorax should
be discouraged from underwater diving permanently, unless a definitive preventative procedure has
been accomplished. Patients should be instructed not to fly for at least 1 week after resolution of a
pneumothorax. Resolution must be confirmed on chest x-ray.
Follow up
Pneumothorax
FOLLOW UP
Monitoring
Monitoring
There is no established guideline for monitoring patients following a spontaneous pneumothorax. Patient
education is, therefore, an important aspect in the treatment of spontaneous pneumothoraces.
Monitor for complications of chest drain insertion. Visceral injury is the most serious complication, but
other more common complications include:[9]
• Pain
• Intrapleural or wound infection
• Drain dislodgement or blockage
• Surgical emphysema.
Organise a follow-up chest x-ray after 2 to 4 weeks to monitor resolution of the pneumothorax for all
patients who were managed with observation alone or by needle aspiration.[9]
Complications
Complications
re-expansion pulmonary oedema
Timeframe
short term
Likelihood
low
If the pneumothorax is large and has been present for more than 72 hours, then the patient is theoretically
at risk for re-expansion pulmonary oedema after pleural space evacuation. It can also develop in the
ipsilateral lung during or immediately following evacuation of air from the pleural space. In addition, the
pulmonary oedema may be evident in the contralateral lung. The oedema may progress for 24 to 48 hours.
Recovery is typically complete within the first 48 hours.
The exact underlying mechanism for this is not known. Mechanical stress applied to the lung during reexpansion may damage the pulmonary capillaries and lead to the development of pulmonary oedema. Reperfusion injury with free radical formation may also play a significant role.[123]
It is associated with variable degrees of hypoxaemia and hypotension, sometimes requiring intubation
and mechanical ventilation, and occasionally leads to death.[124] Because the amount of intrapleural
pressure necessary to induce re-expansion pulmonary oedema is not precisely known, most clinicians err
on the side of safety for the patient and connect the chest tubes placed to a water seal device rather than
to suction. If the lung does not fully re-expand with the water seal device, negative pressure suction (highvolume low-pressure) can be added.
talc pleurodesis-related ARDS
short term
low
It has been suggested that intrapleural injection of talc produces a systemic inflammatory response that
may play a role in the pathogenesis of ARDS.[125] However, talc pleurodesis appears to be safe when
size-calibrated talc is used in the recommended dosages.[126]
60
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Pneumothorax
Follow up
Prognosis
Patients with primary spontaneous pneumothoraces are at risk for recurrent pneumothoraces. Between 30%
and 50% of patients will have an ipsilateral recurrent pneumothorax. Unless an intervention is undertaken
in a patient with a first recurrence, a third and fourth event can be expected in 62% and 83% of patients,
respectively. These patients are also at risk of a contralateral primary spontaneous pneumothorax.[121]
The recurrence rates of primary spontaneous pneumothorax after video-assisted thoracoscopy with
stapling of the subpleural bleb and mechanical pleural abrasion and thoracoscopic talc poudrage are
similar (approximately 5%). Chemical pleurodesis can be accomplished via chest tube if video-assisted
thoracoscopy is not readily available, or if the patient refuses video-assisted thoracoscopy. The failure rate of
chemical pleurodesis is approximately 25%.[9]
Secondary spontaneous pneumothorax
Patients with secondary spontaneous pneumothoraces are at greater risk of recurrences. Because many
lung diseases occur bilaterally, these patients are typically at risk for contralateral secondary spontaneous
pneumothoraces.[122] The intervention taken for a persistent air leak or a recurrent ipsilateral pneumothorax
may depend on available resources.
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FOLLOW UP
Primary spontaneous pneumothorax
Pneumothorax
Guidelines
Diagnostic guidelines
Europe
ERS task force statement: diagnosis and treatment of primary spontaneous
pneumothorax
Published by: European Respiratory Society
Last published: 2015
North America
ACR appropriateness criteria: rib fractures
GUIDELINES
Published by: American College of Radiology
Last published: 2019
Treatment guidelines
Europe
ERS task force statement: diagnosis and treatment of primary spontaneous
pneumothorax
Published by: European Respiratory Society
62
Last published: 2015
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Pneumothorax
Online resources
Online resources
1.
NHS England. National Patient Safety Alert – Blood control safety cannula and needle thoracostomy
for tension pneumothorax. Apr 2020 (external link)
ONLINE RESOURCES
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63
Pneumothorax
References
REFERENCES
Key articles
•
MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of spontaneous
pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug;65(suppl
2):ii18-31. This guideline has been archived by the British Thoracic Society. The BTS website states
that guidelines that are more than 5 years old are marked as archived because their recommendations
have not been checked to confirm continued validity at the date of archival. The expert adviser of this
topic has confirmed that these guidelines still reflect current practice in the UK. Full text Abstract
•
Tschopp JM, Bintcliffe O, Astoul P, et al. ERS task force statement: diagnosis and treatment of primary
spontaneous pneumothorax. Eur Respir J. 2015 Aug;46(2):321-35. Full text Abstract
•
MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of spontaneous
pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug;65(suppl
2):ii18-31. Full text Abstract
References
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2):ii18-31. This guideline has been archived by the British Thoracic Society. The BTS website states
that guidelines that are more than 5 years old are marked as archived because their recommendations
64
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 22, 2024.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.
Pneumothorax
References
have not been checked to confirm continued validity at the date of archival. The expert adviser of this
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65
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subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.
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BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
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BMJ Best Practice topics are regularly updated and the most recent version
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Pneumothorax
Images
Images
IMAGES
Figure 1: Anterior-posterior chest x-ray demonstrating a right pneumothorax
From the collection of Dr Ryland P. Byrd
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 22, 2024.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.
73
Images
IMAGES
Pneumothorax
Figure 2: UK guidelines advise using the level of the hilum to measure the size of a pneumothorax. However,
other countries may use other methods; for example US guidelines use the distance from the lung apex to the
cupola, but this method would tend to overestimate the volume of a localised apical pneumothorax.
Copyright © BMJ Publishing Group Ltd and British Thoracic Society. All rights reserved.
74
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 22, 2024.
BMJ Best Practice topics are regularly updated and the most recent version
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Pneumothorax
Images
IMAGES
Figure 3: Management of spontaneous pneumothorax. CXR = chest x-ray.
Published with permission from the British Thoracic Society. Created by the BMJ Knowledge Centre.
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 22, 2024.
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Pneumothorax
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This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 22, 2024.
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Contributors:
// Expert Advisers:
Jonathan Bennet t, MD
Honorary Professor of Respiratory Sciences
University of Leicester, Respiratory Consultant, Glenfield Hospital, Leicester, UK
DISCLOSURES: JB declares that he has no competing interests.
Claire Vella, MD, MRCP
Clinical Fellow Lung Cancer and Interventional Pulmonology
Glenfield Hospital, Leicester, UK
DISCLOSURES: CV declares that she has no competing interests.
Onyeka Umerah,
Respiratory Registrar
Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
DISCLOSURES: OU declares that she has no competing interests.
Acknowledgements,
BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose
work has been retained in parts of the content:
Lonny Yarmus, DO, MBA, Associate Professor of Medicine and Oncology, Clinical Director, Division
of Pulmonary and Critical Care, Director, Interventional Pulmonology Research Core, Johns Hopkins
Medical Institutions, Baltimore, MD, Jason Akulian, MD, MPH, Assistant Professor of Medicine, Director,
Interventional Pulmonology, Carolina Center for Pleural Disease, University of North Carolina, Chapel Hill,
NC
DISCLOSURES: LY has received research grants and consulting fees from Olympus, Inc, the manufacturer
of the Spiration intrabronchial valve. JA declares that he has no competing interests.
// Peer Reviewers:
Mat thew Knight, PGCertEd MD FRCP FRCP(Edin)
Associate Postgraduate Dean
Health Education England, Royal College of Physicians College Tutor, Consultant Respiratory Physician,
Watford General Hospital, West Hertfordshire Hospitals NHS Trust
DISCLOSURES: MK was collaborator and site principal investigator for the randomised ambulatory
management of primary pneumothorax (RAMPP) trial, which received funding from Rocket Medical. MK has
attended meetings sponsored by Rocket Medical.
// Editors:
Annabel Sidwell,
Section Editor, BMJ Best Practice
DISCLOSURES: AS declares that she has no competing interests.
Anna Ellis,
Head of Editorial, BMJ Best Practice
DISCLOSURES: AE declares that she has no competing interests.
Rachel Wheeler,
Lead Section Editor, BMJ Best Practice
DISCLOSURES: RW declares that she has no competing interests.
Julie Costello,
Comorbidities Editor, BMJ Best Practice
DISCLOSURES: JC declares that she has no competing interests.
Adam Mitchell,
Drug Editor, BMJ Best Practice
DISCLOSURES: AM declares that he has no competing interests.