Pneumothorax
Tension pneumothorax: NICE Guideline [NG39] Major trauma: assessment and initial management. Spontaneous pneumothorax: British Thoracic Society (BTS) Guideline for Pleural Disease 2023
Background Information
Spontaneous pneumothorax: presence of air in the pleural space, between the visceral and parietal pleura that occurs in the absence of trauma or causative medical intervention.
Spontaneous pneumothorax can be sub-classified into:
- Primary spontaneous pneumothorax (PSP): in the absence of underlying lung diseases
- Secondary spontaneous pneumothorax (SSP): in the presence of underlying lung disease OR ≥ 50 y/o with a significant smoking history
Symptoms:
- Sudden onset pleuritic chest pain
- Sudden onset dyspnoea
Examination findings on the affected side:
- Reduced / absent breath sound
- Hyper-resonant percussion
- Reduced chest expansion
Additional findings in tension pneumothorax:
- Trachea deviation
- Haemodynamic instability
- Distended neck veins
Tension Pneumothorax Guidelines
Recommendations by the American College of Surgeon ATLS 10th Edition: (traditionally taught in medical school)
- Immediate management: or finger thoracostomy
- Latest recommended site: 4th/5th intercostal space, mid-axillary line
- Traditional site: 2nd intercostal space, mid-clavicular line
- Followed by chest drain insertion
NICE recommends performing chest decompression initially with finger thoracostomy followed by chest drain insertion.
Do not delay interventions to obtain imaging if tension pneumothorax is suspected, esp. if there is haemodynamic instability or severe respiratory compromise.
Spontaneous Pneumothorax Guidelines
BTS 2023 management pathway is driven by whether the patient is symptomatic or not.
Expected pneumothorax resolution time:
Assess for high-risk characteristics:
Subsequent care following chest drain insertion
Patient factors:
- ≥ 50 y/o with significant smoking history
- Presence of underlying lung disease (i.e. secondary pneumothorax)
- Significant hypoxia
Pneumothorax factors:
- Haemodynamic compromise (suggesting tension pneumothorax)
- Bilateral pneumothorax
- Haemopneumothorax
If → chest drain insertion
Subsequent care following chest drain insertion
- Admit as inpatient with daily review
- Remove chest drain when resolved
- Discharge and review as outpatient in 2-4 weeks
If → offer ANY of the following depending on patient's main priority
Conservative care if patient wishes to avoid procedures
- Primary spontaneous pneumothorax→ review as outpatient every 2-4 days
- Secondary spontaneous pneumothorax → admit as inpatient and give high-flow oxygen
Needle aspiration for rapid symptom relief
- If resolved → discharge and review as outpatient in 2-4 weeks
- If not resolved → chest drain insertion
Ambulatory device if locally available (preferred in PSP)
- Review as outpatient every 2-3 days
- Remove device when resolved
- If stable → follow up as outpatient in 2-4 weeks
Always offer conservative care regardless of pneumothorax size
- If Primary spontaneous pneumothorax (PSP) → discharge and review as outpatient every 2-4 days
- If Secondary spontaneous pneumothorax (SSP) → admit as inpatient for a minimum of 24 hours with supplemental oxygen
Expected pneumothorax resolution time:
- 1cm pneumothorax → around 10 days
- 2cm pneumothorax → after 2-3 weeks
- Return to emergency department immediately if ever develop further breathlessness
- Advise smoking cessation to reduce risk of recurrence
- Patients can only fly 7 days after full resolution confirmed on CXR
- Patients should be advised to permanently avoid diving, unless a definitive preventive strategy has been performed (e.g., surgical pleurectomy)
References
ATLS® Advanced Trauma Life Support® Student Course Manual 10th Edition. 2018 American College of Surgeons.
NICE Guidelines on Tension Pneumothorax
BTS Spontaneous Pneumothorax Guidelines (2023)
NICE Guidelines on Tension Pneumothorax
BTS Spontaneous Pneumothorax Guidelines (2023)