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Pneumothorax

NICE Guideline [NG39] Major trauma: assessment and initial management. 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 medical intervention.
 

Tension pneumothorax is a life-threatening condition characterised by intrapleural pressure rises sufficiently to cause significant hemodynamic compromise, typically due to a one-way valve effect that traps air in the pleural space.

Causes of pneumothorax are classically divided into the following: [Ref1][Ref2]

Category Causes
Spontaneous pneumothorax

Spontaneous pneumothorax occurs spontaneously, without any preceding trauma / medical intervention.

Spontaneous pneumothorax can be sub-classified into:

  • Primary spontaneous pneumothorax (PSP): occurs in otherwise healthy individuals without known lung diseases
    • Risk factor: young, tall, thin males
    • Most have subclinical lung abnormalities (e.g. subpleural blebs ur bullae)
 
  • Secondary spontaneous pneumothorax (SSP): occurs in individuals with underlying lung disease (e.g. COPD, asthma, cystic fibrosis) OR ≥50 y/o with a significant smoking history
    • These patients' alveoli are more prone to rupture from chronically increased alveolar pressure or lung tissue necrosis
Traumatic pneumothorax
  • Penetrating chest trauma (e.g. gunshot wound, stab wound)
  • Blunt chest trauma (e.g. motor vehicle accident)
Iatrogenic pneumothorax
  • Mechanical ventilation
  • Central venous catheter placement
  • Thoracocentesis
  • Lung biopsy
  • Bronchoscopy

Any type of pneumothorax can evolve into tension pneumothorax, however the risk is greater in traumatic and iatrogenic pneumothorax. [Ref]

Risk is highest in mechanically ventilated patients. [Ref]

  • Progression into tension pneumothorax
    • Any type of pneumothorax can evolve into tension pneumothorax, however the risk is greater in traumatic and iatrogenic pneumothorax [Ref]
    • Risk is highest in mechanically ventilated patients [Ref]
  • Persistent air leak / failure of lung re-expansion
  • Respiratory failure
  • Obstructive shock (mostly seen in tension pneumothorax, where the mediastinal shift compresses the great veins and reduces preload)

  • Recurrence is common (>50% recurrence risk after 1st episode, higher in the presence of underlying lung disease)
  • Persistent air leak and failure of lung re-expansion

Diagnosis

Sudden onset of:
  • Pleuritic chest pain
  • Dyspnoea

Typical respiratory examination findings:
Examination aspect Typical findings
Chest expansion ↓ on the affected side (due to pain)
Percussion Hyper-resonant over the affected area
Tactile fremitus ↓  on the affected side
Auscultation Reduced / absent breath sound over the affected area

Additional findings that suggest tension pneumothorax:

  • Trachea deviation (away from the affected side)
  • Haemodynamic instability
  • Distended neck veins

1st line: chest X-ray 
  • Typical finding is a visible pleural line with lung markers only visible up to this line, no longer visible beyond the pleural line
  • Ultrasound is increasingly used to identify pneumothorax (e.g. in eFAST)

2nd line (if chest X-ray is equivocal): CT chest

Tension pneumothorax should be a clinical diagnosis. Do not delay interventions to obtain imaging if tension pneumothorax is suspected.

Management

Immediate management: chest decompression with  needle decompression or finger thoracostomy
  • Latest recommended site: 4th/5th intercostal space, mid-axillary line
  • Traditional site: 2nd intercostal space, mid-clavicular line
 
Definitive management: chest drain insertion (insert a chest drain AFTER initial chest decompression)

Tension pneumothorax should be a clinical diagnosis. Do not delay interventions to obtain imaging if tension pneumothorax is suspected.

Full decision algorithm:

Assess for high-risk characteristics:
  • Patient factors:
    • ≥ 50 y/o with significant smoking history
    • Presence of underlying lung disease (i.e. secondary pneumothorax)
    • Significant hypoxia
  • Pneumothorax factors:
    • Haemodynamic compromise
    • Bilateral pneumothorax
    • Haemopneumothorax

Subsequent action, depends on whether high-risk characteristics are present or not.

If  safe to intervene → 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 safe to intervene → offer ANY of the following depending on the patient's main priority
Goal Management pathway Description
Patient wishes to avoid procedures Conservative management
  • PSPPrimary spontaneous pneumothorax→ review as outpatient every 2-4 days
  • SSPSecondary spontaneous pneumothorax → admit as inpatient and give high-flow oxygen
Rapid symptomatic relief Needle aspiration
  • If resolved → discharge and review as outpatient in 2-4 weeks
  • If not resolved → chest drain insertion
If locally available (preferred in PSPPrimary spontaneous pneumothorax Ambulatory device
  • 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 PSPPrimary spontaneous pneumothorax (PSP)  → discharge and review as outpatient every 2-4 days
  • If SSPSecondary spontaneous pneumothorax (SSP)  → admit as inpatient for a minimum of 24 hours with supplemental oxygen

Expected pneumothorax resolution time:

  • 1cm pneumothorax → ~10 days
  • 2cm pneumothorax → after 2-3 weeks

  • Return to emergency department immediately if further breathlessness develops
  • 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)

Author: Adams Lau
Last edited: 02/10/25