Pneumothorax

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

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 line – immediate decompression

Plus – high-flow oxygen

Plus – chest drain + hospital admission

Back

Plus –

chest drain + hospital admission

Treatment recommended for ALL patients in selected patient group

Insert a chest drain immediately after decompression.[17]

Only insert a chest drain if you have had adequate training and are appropriately supervised.[65]

Obtain written consent, unless the patient is critically unwell.

Insertion of intercostal drain, Seldinger technique: animated demonstration

How to insert an intercostal (chest) drain using the Seldinger technique. Video demonstrates: how to identify a safe site for insertion; use of an introducer needle, guidewire, dilators, and intercostal drain; how to confirm drain position; and post-procedure care.

Insertion of intercostal drain, open technique: animated demonstration

How to insert an intercostal (chest) drain using the open technique. Video demonstrates: tube selection, how to identify the site for drain insertion, how to make the correct incision, how to insert the intercostal drain, how to secure the drain, and post-procedure care.

Following insertion of a chest drain it is essential to:[81]

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).

Only remove a chest drain based on senior or specialist advice.

Primary options

ibuprofen: 300-600 mg orally (immediate-release) 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

oxycodone: 5 mg orally (immediate-release) every 4-6 hours initially, adjust dose according to response, maximum 400 mg/day; 1-10 mg intravenously every 4 hours when required

ACUTE

confirmed spontaneous pneumothorax

asymptomatic

1st line – observation ± supplemental oxygen

Back

1st line –

observation ± supplemental oxygen

Consider conservative management if patients are asymptomatic with normal observations.

Review patients undergoing conservative care regularly:[17][74]

Patients with a primary spontaneous pneumothorax (PSP) can be reviewed regularly as an outpatient (i.e., every 2-4 days until stable)
Patients with a secondary spontaneous pneumothorax (SSP) should be reviewed as inpatients.

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).[42] 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.[42][67]

symptomatic with no high-risk characteristics; procedural avoidance a priority

1st line – observation ± supplemental oxygen

Back

1st line –

observation ± supplemental oxygen

Consider conservative management if patients are symptomatic with normal observations and no high-risk characteristics.[17][74]

symptomatic with no high-risk characteristics; rapid symptom relief a priority

1st line – percutaneous aspiration or ambulatory device or consider surgery

Consider – chest drain + hospital admission

Back

Consider –

chest drain + hospital admission

Additional treatment recommended for SOME patients in selected patient group

If percutaneous aspiration is unsuccessful (visible rim >2 cm on chest x-ray), insert chest drain and admit.

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 jirovecii infection.[17][88]

Correct clotting abnormalities (INR ≥1.5 and platelets ≤50 x 10⁹/L) before insertion of a chest drain in patients who are not critically unwell.[17][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).[43]

Only insert a chest drain if you have had adequate training and are appropriately supervised.[65]

Obtain written consent, unless the patient is critically unwell.

Insertion of intercostal drain, Seldinger technique: animated demonstration

Insertion of intercostal drain, open technique: animated demonstration

Following insertion of a chest drain it is essential to:[81]

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 (high-volume low-pressure systems) if there is a persistent air leak (i.e., the chest drain continues to bubble) for ≥48 hours.[17]

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.[17]

Primary options

ibuprofen: 300-600 mg orally (immediate-release) 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

oxycodone: 5 mg orally (immediate-release) every 4-6 hours initially, adjust dose according to response, maximum 400 mg/day; 1-10 mg intravenously every 4 hours when required

Consider – supplemental oxygen

symptomatic with high-risk characteristics

1st line – chest drain + hospital admission

Back

1st line –

chest drain + hospital admission

For symptomatic patients, providing pneumothorax is of sufficient size. The British Thoracic Society states that this will depend on the clinical context but is generally a pneumothorax ≥2 cm in size laterally or apically on chest x-ray, or any size on computed tomography scan that can be safely accessed with radiological support.[17]

In patients with cystic fibrosis, a small asymptomatic pneumothorax can be observed or aspirated, but larger pneumothoraces require a chest drain.[17]

Correct clotting abnormalities (INR ≥1.5 and platelets ≤50 x 10⁹/L) before insertion of a chest drain in patients who are not critically unwell.[17][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).[43]

Only insert a chest drain if you have had adequate training and are appropriately supervised.[65]

Obtain written consent, unless the patient is critically unwell.

Insertion of intercostal drain, Seldinger technique: animated demonstration

Insertion of intercostal drain, open technique: animated demonstration

Following insertion of a chest drain it is essential to:[81]

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 (high-volume low-pressure systems) if there is a persistent air leak (i.e., the chest drain continues to bubble) for ≥48 hours.[17]

Only remove a chest drain based on senior or specialist advice.

Primary options

ibuprofen: 300-600 mg orally (immediate-release) 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

oxycodone: 5 mg orally (immediate-release) every 4-6 hours initially, adjust dose according to response, maximum 400 mg/day; 1-10 mg intravenously every 4 hours when required

Consider – supplemental oxygen

Consider – surgery or talc pleurodesis

Back

Consider –

surgery or talc pleurodesis

Additional 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:[17]

Persistent air leak
Failure of the lung to re-expand.

Options include open thoracotomy or video-assisted thoracoscopic surgery (VATS).[17]

There are some circumstances where thoracic surgery would be considered at initial presentation if recurrence prevention is deemed important (e.g., in patients presenting with tension pneumothorax, or those in high-risk occupations).[17]

If the patient has a secondary spontaneous pneumothorax, but is unable or unwilling to undergo surgery, options include:[17]

Chemical pleurodesis. This should only be performed by a respiratory specialist.
Ambulatory management with a Heimlich one-way valve.[104]

confirmed traumatic non-tension pneumothorax

1st line – high-flow oxygen + observation + refer to thoracic surgeon

Back

1st line –

high-flow oxygen + observation + refer to thoracic surgeon

Give high-flow oxygen 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.[17][42]

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).[42] 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.[42][67]

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.[12]

Do not aspirate a traumatic pneumothorax.

Never leave a patient with a penetrating chest wound or open pneumothorax unattended as tension pneumothorax may develop. Cover the wound with a simple occlusive dressing and observe closely.[43][47]

Give a dose of prophylactic antibiotics if a chest drain is being inserted to decrease the risk of empyema and pneumonia. Check local protocols.[82]

confirmed pneumothorax ex vacuo

1st line – high-flow oxygen

Back

1st line –

high-flow oxygen

Consider – bronchoscopy

confirmed catamenial pneumothorax

1st line – hormonal manipulation ± surgery

ONGOING

acute pneumothorax resolved

1st line – prevention of recurrence

Back

1st line –

prevention of recurrence

Give patients the following advice prior to discharge:

They should avoid diving permanently, unless a definitive prevention strategy has been performed, such as surgical pleurectomy
They should avoid air travel until full resolution of the pneumothorax; resolution must be confirmed on chest x-ray[98]
They should be given smoking cessation advice; smoking influences the risk of recurrence.[17] Smoking cessation reduces this risk fourfold.[8]

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:

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:

Hormonal manipulation to suppress ovulation and menstruation for patients with catamenial pneumothorax[85]
Treatment for HIV and any associated Pneumocystis jirovecii infection for patients with HIV
Early discussion with a surgeon for patients with cystic fibrosis. Chest tube drainage alone has a recurrence rate of 50% in patients with cystic fibrosis, but with interventions such as pleurectomy, pleural abrasion and pleurodesis recurrence can be reduced.[90][91]

persistent air leak

1st line – surgery

1st line – blood pleurodesis or endobronchial therapies

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Pneumothorax

Treatment algorithm

suspected tension pneumothorax

immediate decompression

high-flow oxygen

chest drain + hospital admission

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

confirmed spontaneous pneumothorax

asymptomatic

observation ± supplemental oxygen

symptomatic with no high-risk characteristics; procedural avoidance a priority

observation ± supplemental oxygen

symptomatic with no high-risk characteristics; rapid symptom relief a priority

percutaneous aspiration or ambulatory device or consider surgery

chest drain + hospital admission

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

supplemental oxygen

symptomatic with high-risk characteristics

chest drain + hospital admission

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

supplemental oxygen

surgery or talc pleurodesis

confirmed traumatic non-tension pneumothorax

high-flow oxygen + observation + refer to thoracic surgeon

confirmed pneumothorax ex vacuo

high-flow oxygen

bronchoscopy

confirmed catamenial pneumothorax

hormonal manipulation ± surgery

acute pneumothorax resolved

prevention of recurrence

persistent air leak

surgery

blood pleurodesis or endobronchial therapies