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

tension pneumothorax

1st line – immediate decompression

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INITIAL
|
tension pneumothorax
1st line – 

immediate decompression

Immediate decompression is required. Intervention should not be delayed by waiting for imaging results to confirm the diagnosis, unless point of care ultrasound (POCUS) is readily available to confirm lung point or lack of lung sliding.[24]​​

Needle decompression of tension pneumothorax: animated demonstration
Needle decompression of tension pneumothorax: animated demonstration

How to decompress a tension pneumothorax. Demonstrates insertion of a large-bore intravenous cannula into the fourth intercostal space in an adult.

If the tension pneumothorax is not secondary to trauma, a large-bore cannula (e.g., a 14-Fr angiocath) should be inserted into the pleural space through the second intercostal space in the midclavicular line or the fourth or fifth intercostal space in the midaxillary line.[24]​​[57]​​​ A "hiss" of air confirms the diagnosis. 

If the tension pneumothorax is secondary to trauma, open thoracotomy for decompression is recommended if the expertise is available.[58] The Advanced Trauma Life Support guideline recommends using the fourth or fifth intercostal space in the midaxillary line as first-line if needle decompression is required.[59]

Plus – oxygen therapy

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INITIAL
|
tension pneumothorax
Plus – 

oxygen therapy

Treatment recommended for ALL patients in selected patient group

Supplemental high-concentration (>10L/minute) oxygen should be administered via a nonrebreather face mask.

Plus – tube thoracostomy

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INITIAL
|
tension pneumothorax
Plus – 

tube thoracostomy

Treatment recommended for ALL patients in selected patient group

After needle decompression, the patient will require a chest tube or small-bore catheter to reduce the risk of an immediate recurrence of the tension pneumothorax. If chest tube kit is readily available, this can be the first step and definitive management.

ACUTE

primary spontaneous pneumothorax AND patient ≤ 50 years old

1st line – supplemental oxygen therapy and observation

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ACUTE
|
primary spontaneous pneumothorax AND patient ≤ 50 years old
|
small (visible rim of ≤2 cm between the lung margin and the chest wall) and no breathlessness
1st line – 

supplemental oxygen therapy and observation

Supplemental high-concentration (10 L/minute+) oxygen should be given. The addition of high-concentration oxygen therapy has been shown to result in a 4-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation.[62]

Clinically stable patients who are experiencing a small primary spontaneous pneumothorax can be observed and treated conservatively with supplemental high-concentration (10 L/minute) oxygen and observation, without invasive intervention.[61]

As these patients are typically young and otherwise healthy, they can often be managed as outpatients. If they remain stable in the emergency room for 4 to 6 hours (including serial imaging studies), they can be released with follow-up in several days. However, they should be instructed to seek medical attention immediately should they become short of breath. Patient’s ability to easily follow-up should also be taken into account in the decision-making process.

1st line – supplemental oxygen therapy and percutaneous aspiration or conservative management

Back
ACUTE
|
primary spontaneous pneumothorax AND patient ≤ 50 years old
|
breathless or otherwise symptomatic with large (visible rim >2 cm) between the lung margin and the chest wall
1st line – 

supplemental oxygen therapy and percutaneous aspiration or conservative management

Supplemental high-concentration (10 L/minute) oxygen should be given. The addition of high-concentration oxygen therapy has been shown to result in a 4-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation.[62]

If the primary spontaneous pneumothorax is large, needle aspiration is generally safe and effective. Often the procedure can be accomplished in the emergency department without admission to the hospital.[24][63][64]​ However, recent literature has demonstrated noninferiority of conservative management as long as there is close follow-up, therefore patient symptoms should guide therapy as opposed to arbitrary size cutoffs.[68]​ Conservative management may be considered if patients are asymptomatic with normal observations.[68][69][70] If intervention is deemed necessary, this can be accomplished by the placement of an intravenous cannula into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. A large syringe can then be used to withdraw air from the pleural space. Care must be taken not to allow air to gain access to the pleural space via the cannula. Coaching the patient to exhale while the syringe is detached from the cannula can prevent this. Alternatively, a stopcock attached to the catheter offers the advantage of sealing the pleural space from the atmosphere when the syringe is disconnected from the stopcock. 

Once no further air can be aspirated from the cannula, it should be removed.

A chest x-ray should be obtained to confirm resolution or the need for further treatment.

Case series data shows that patients above 50 years old may respond differently to needle aspiration.[24]​ This is largely thought to be as a result of unrecognized underlying pulmonary disease in this age group. Therefore, it is recommended that patients above 50 years old, particularly those with a significant smoking history, should be treated with the assumption of an underlying respiratory disease (i.e., treated as a secondary spontaneous pneumothorax).[24]​​

Consider – chest-tube thoracostomy

Back
ACUTE
|
primary spontaneous pneumothorax AND patient ≤ 50 years old
|
breathless or otherwise symptomatic with large (visible rim >2 cm) between the lung margin and the chest wall
Consider – 

chest-tube thoracostomy

Treatment recommended for SOME patients in selected patient group

If aspiration fails, a chest tube or small-bore catheter should be inserted.

Small-bore catheters can be attached to a one-way flutter valve and usually do not require negative pressure suction.[24]​​[52]

Insertion of intercostal drain, Seldinger technique: animated demonstration
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 postprocedure care.

Consider – suction

Back
ACUTE
|
primary spontaneous pneumothorax AND patient ≤ 50 years old
|
breathless or otherwise symptomatic with large (visible rim >2 cm) between the lung margin and the chest wall
Consider – 

suction

Treatment recommended for SOME patients in selected patient group

There is insufficient evidence to make any recommendations on the best treatment method for pneumothorax and persistent air leak in adults.[24]​ Although there is no evidence to support the routine use of suction in the management of pneumothorax, in select patients it is thought to help cause the apposition of the visceral and parietal pleura; thereby promoting healing of the air leak.[24]​​[52]

Most suction devices have a water-filled chamber through which air is removed from the pleural space. A persistent air leak is easy to identify by the bubbling seen in the drain.

Consider – video-assisted thoracoscopy with stapling of the air leak and pleurodesis

Back
ACUTE
|
primary spontaneous pneumothorax AND patient ≤ 50 years old
|
breathless or otherwise symptomatic with large (visible rim >2 cm) between the lung margin and the chest wall
Consider – 

video-assisted thoracoscopy with stapling of the air leak and pleurodesis

Treatment recommended for SOME patients in selected patient group

Video-assisted thoracoscopy (VATS) with stapling of the air leak and pleurodesis may be suitable in some instances. Compared with open pleurectomy for primary spontaneous pneumothoraces, VATS results in reductions in length of hospitalization and analgesic requirements for pain control. Recurrence rates, however, are higher following VATS pleurectomy than following open pleurectomy.[71][72]​​​

Thoracoscopic wedge resection is an alternative procedure to stem the air leak should it persist. This is often performed together with mechanical pleurodesis to prevent recurrence of the pneumothorax. However, the addition of mechanical pleurodesis does not appear to reduce the rate of recurrence when compared with wedge resection alone.[73] In addition, patients receiving wedge resection and mechanical pleurodesis have higher rates of intraoperative bleeding and postoperative pleural drainage rates.[73] Rather than performing mechanical pleurodesis following wedge resection, there is some evidence to suggest that visceral pleural coverage of the staple line with absorbable cellulose mesh and fibrin glue is equivalent to mechanical pleurodesis without the associated potential complications.[74]

In nonoperative candidates, autologous blood patch, talc slurry via chest tube (or other sclerosant) pleurodesis, or endobronchial one-way valve placement can be considered.[75][76]​​[77]​​

Insertion of intercostal drain, Seldinger technique: animated demonstration
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 postprocedure care.

secondary spontaneous pneumothorax OR patient > 50 years old

1st line – hospitalization and supplemental oxygen

Back
ACUTE
|
secondary spontaneous pneumothorax OR patient > 50 years old
|
small (visible rim <1 cm between the lung margin and the chest wall) and no breathlessness
1st line – 

hospitalization and supplemental oxygen

Because of diminished pulmonary reserve, patients with secondary spontaneous pneumothoraces should be hospitalized.

Supplemental high-concentration (10 L/minute) oxygen should be given where feasible. Oxygen should be used with caution in patients with chronic lung disease who are at risk of hypercapnic respiratory failure.

Plus – observation

Back
ACUTE
|
secondary spontaneous pneumothorax OR patient > 50 years old
|
small (visible rim <1 cm between the lung margin and the chest wall) and no breathlessness
Plus – 

observation

Treatment recommended for ALL patients in selected patient group

In clinically stable patients with small pneumothoraces (<1 cm), no further treatment may be required. They should, however, be observed for at least 24 hours in hospital.

1st line – hospitalization and supplemental oxygen

Back
ACUTE
|
secondary spontaneous pneumothorax OR patient > 50 years old
|
moderate (visible rim 1 cm to 2 cm between the lung margin and the chest wall) and no breathlessness
1st line – 

hospitalization and supplemental oxygen

Because of diminished pulmonary reserve, patients with secondary spontaneous pneumothoraces should be hospitalized.

Supplemental high-concentration (10 L/minute) oxygen should be given where feasible. Oxygen should be used with caution in patients with chronic lung disease who are at risk of hypercapnic respiratory failure.

Plus – percutaneous aspiration

Back
ACUTE
|
secondary spontaneous pneumothorax OR patient > 50 years old
|
moderate (visible rim 1 cm to 2 cm between the lung margin and the chest wall) and no breathlessness
Plus – 

percutaneous aspiration

Treatment recommended for ALL patients in selected patient group

In patients with moderately-sized pneumothoraces (1 cm to 2 cm), needle aspiration may be attempted. However, the success rate of this procedure is limited in patients with secondary spontaneous pneumothoraces.

Consider – chest-tube thoracostomy

Back
ACUTE
|
secondary spontaneous pneumothorax OR patient > 50 years old
|
moderate (visible rim 1 cm to 2 cm between the lung margin and the chest wall) and no breathlessness
Consider – 

chest-tube thoracostomy

Treatment recommended for SOME patients in selected patient group

In patients where needle aspiration fails, or in symptomatic patients with high-risk characteristics, a chest drain can be inserted. Most patients with secondary spontaneous pneumothoraces will require a chest tube or small-bore catheter given poor healing associated with underlying lung disease.​

Insertion of intercostal drain, Seldinger technique: animated demonstration
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 postprocedure care.

Consider – suction

Back
ACUTE
|
secondary spontaneous pneumothorax OR patient > 50 years old
|
moderate (visible rim 1 cm to 2 cm between the lung margin and the chest wall) and no breathlessness
Consider – 

suction

Treatment recommended for SOME patients in selected patient group

There is insufficient evidence to make any recommendations on the best treatment method for pneumothorax and persistent air leak in adults.[24]​ Although there is no evidence to support the routine use of suction in the management of pneumothorax, in select patients it is thought to help cause the apposition of the visceral and parietal pleura, thereby promoting healing of the air leak.​[52]

Most suction devices have a water-filled chamber through which air is removed from the pleural space. A persistent air leak is easy to identify by the bubbling seen in the drain.

Consider – video-assisted thoracoscopy or pleurodesis

Back
ACUTE
|
secondary spontaneous pneumothorax OR patient > 50 years old
|
moderate (visible rim 1 cm to 2 cm between the lung margin and the chest wall) and no breathlessness
Consider – 

video-assisted thoracoscopy or pleurodesis

Treatment recommended for SOME patients in selected patient group

If the pneumothorax fails to resolve and there is an ongoing air-leak, or the patient has recurrent pneumothoraces, the patient may require VATS with stapling of the air leak and pleurodesis.[24]​ This is more effective than chemical pleurodesis. However, the perioperative morbidity and mortality of VATS in patients with secondary spontaneous pneumothorax may be prohibitively high.[24]​​[52][53]​​ In view of the significant risk of morbidity and mortality after VATS or open thoracotomy, less invasive measures may be tried, especially in patients with severe pulmonary disease, whether due to COPD, cystic fibrosis, or another lung disorder. In nonoperative candidates, autologous blood patch, talc slurry via chest tube (or other sclerosant) pleurodesis, or endobronchial one-way valve placement can be considered.[75][76][77]​​ Talc pleurodesis should also be considered on the first episode of pneumothorax in high-risk patients in whom repeat pneumothorax would be hazardous (e.g., severe COPD).[24]

Subsequent interventions are aimed at preventing recurrences. In general, the chest tube should remain in place until a procedure is performed to prevent recurrent pneumothorax.[24]​​[52][53]

While all patients with a secondary spontaneous pneumothorax should be considered for a preventive intervention, patients who are possible lung transplantation candidates require special consideration. Diffuse pleurodesis with either VATS or intrapleural chemical instillation should be avoided in patients with cystic fibrosis or alpha-1 antitrypsin deficiency, and in younger patients with smoking-related COPD who are being considered for lung transplant. Previous diffuse pleurodesis results in a more difficult and bloody dissection during the lung transplantation procedure. Conservative measures and observation or VATS without directed mechanical abrasion are preferred in this subset of patients.

1st line – hospitalization and supplemental oxygen

Back
ACUTE
|
secondary spontaneous pneumothorax OR patient > 50 years old
|
breathless or otherwise symptomatic with large (visible rim >2 cm) between the lung margin and the chest wall
1st line – 

hospitalization and supplemental oxygen

Because of diminished pulmonary reserve, patients with secondary spontaneous pneumothoraces should be hospitalized.

Supplemental high-concentration (10 L/minute) oxygen should be given where feasible. Oxygen should be used with caution in patients with chronic lung disease who are at risk of hypercapnic respiratory failure.

Plus – chest-tube thoracostomy

Back
ACUTE
|
secondary spontaneous pneumothorax OR patient > 50 years old
|
breathless or otherwise symptomatic with large (visible rim >2 cm) between the lung margin and the chest wall
Plus – 

chest-tube thoracostomy

Treatment recommended for ALL patients in selected patient group

In patients where needle aspiration fails, or in symptomatic patients with high-risk characteristics, a chest drain can be inserted. Most patients with secondary spontaneous pneumothoraces will require a chest tube or small-bore catheter given poor healing associated with underlying lung disease.

Insertion of intercostal drain, Seldinger technique: animated demonstration
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 postprocedure care.

Consider – suction

Back
ACUTE
|
secondary spontaneous pneumothorax OR patient > 50 years old
|
breathless or otherwise symptomatic with large (visible rim >2 cm) between the lung margin and the chest wall
Consider – 

suction

Treatment recommended for SOME patients in selected patient group

There is insufficient evidence to make any recommendations on the best treatment method for pneumothorax and persistent air leak in adults.[24] Although there is no evidence to support the routine use of suction in the management of pneumothorax, in these select patients it is thought to help cause the apposition of the visceral and parietal pleura, thereby promoting healing of the air leak.[24]​​[52]

Most suction devices have a water-filled chamber through which air is removed from the pleural space. A persistent air leak is easy to identify by the bubbling seen in the drain.

Consider – video-assisted thoracoscopy or pleurodesis

Back
ACUTE
|
secondary spontaneous pneumothorax OR patient > 50 years old
|
breathless or otherwise symptomatic with large (visible rim >2 cm) between the lung margin and the chest wall
Consider – 

video-assisted thoracoscopy or pleurodesis

Treatment recommended for SOME patients in selected patient group

If the pneumothorax fails to resolve and there is an ongoing air-leak, or the patient has recurrent pneumothoraces, the patient may require VATS with stapling of the air leak and pleurodesis.[24]​ This is more effective than chemical pleurodesis. However, the perioperative morbidity and mortality of VATS in patients with secondary spontaneous pneumothorax may be prohibitively high.[24]​​[52][53]​​ In view of the significant risk of morbidity and mortality after VATS or open thoracotomy, less invasive measures may be tried, especially in patients with severe pulmonary disease, whether due to COPD, cystic fibrosis, or another lung disorder. In nonoperative candidates, autologous blood patch, talc slurry via chest tube (or other sclerosant) pleurodesis, or endobronchial one-way valve placement can be considered.[75][76][77]

Subsequent interventions are aimed at preventing recurrences. In general, the chest tube should remain in place until a procedure is performed to prevent recurrent pneumothorax.[24]​​[52][53]​​

While all patients with a secondary spontaneous pneumothorax should be considered for a preventive intervention, patients who are possible lung transplantation candidates require special consideration. Diffuse pleurodesis with either VATS or intrapleural chemical instillation should be avoided in patients with cystic fibrosis or alpha-1 antitrypsin deficiency, and in younger patients with smoking-related COPD who are being considered for lung transplant. Previous diffuse pleurodesis results in a more difficult and bloody dissection during the lung transplantation procedure. Conservative measures and observation or VATS without directed mechanical abrasion are preferred in this subset of patients.

traumatic pneumothorax

1st line – hospitalization and supplemental oxygen

Back
ACUTE
|
traumatic pneumothorax
1st line – 

hospitalization and supplemental oxygen

Supplemental high-concentration (10 L/minute) oxygen should be given where feasible. Oxygen should be used with caution in patients with chronic lung disease and hypercapnic respiratory failure.

Plus – percutaneous aspiration

Back
ACUTE
|
traumatic pneumothorax
Plus – 

percutaneous aspiration

Treatment recommended for ALL patients in selected patient group

Percutaneous needle aspiration can be accomplished by placement of an intravenous cannula into the pleural space at the intersection of the midclavicular line and the second or third intercostal space on the side of the pneumothorax. A large syringe can then be used to withdraw air from the pleural space.

Care must be taken not to allow air to gain access to the pleural space via the cannula. Coaching the patient to exhale while the syringe is detached from the catheter can prevent this. Alternatively, a stopcock attached to the cannula offers the advantage of sealing the pleural space from the atmosphere when the syringe is disconnected from the stopcock.

Consider – chest-tube thoracostomy

Back
ACUTE
|
traumatic pneumothorax
Consider – 

chest-tube thoracostomy

Treatment recommended for SOME patients in selected patient group

If aspiration fails or the pneumothorax is large, chest tube placement is usually required.

Insertion of intercostal drain, Seldinger technique: animated demonstration
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 postprocedure care.

A hemothorax may accompany and/or complicate a traumatic pneumothorax. The presence of a hemothorax necessitates chest tube placement.[24]​​

Consider – thoracotomy

Back
ACUTE
|
traumatic pneumothorax
Consider – 

thoracotomy

Treatment recommended for SOME patients in selected patient group

May be needed in some patients to repair tears in the lungs or air passages. Thoracotomy is an operative procedure where the surgeon gains access to the pleural space by making an incision into the chest wall and spreading the ribs apart. There are several different methods to perform a thoracotomy, but posterolateral thoracotomy is the approach most commonly used. Upon completion, the chest incision is closed and 1 or more chest tubes are placed into the pleural space.

pneumothorax ex vacuo

1st line – hospitalization and supplemental oxygen

Back
ACUTE
|
pneumothorax ex vacuo
1st line – 

hospitalization and supplemental oxygen

Supplemental high-concentration (10 L/minute) oxygen should be given where feasible. Oxygen should be used with caution in patients with chronic lung disease who are at risk of hypercapnic respiratory failure.

Consider – bronchoscopy

Back
ACUTE
|
pneumothorax ex vacuo
Consider – 

bronchoscopy

Treatment recommended for SOME patients in selected patient group

Bronchoscopy may be necessary to relieve the endobronchial obstruction.

Tube thoracostomy is not indicated.[4] The pneumothorax spontaneously resolves when the bronchial obstruction is relieved and the lobe re-expands.

catamenial pneumothorax

1st line – hormonal therapy or video assisted thoracoscopy

Back
ACUTE
|
catamenial pneumothorax
1st line – 

hormonal therapy or video assisted thoracoscopy

The acute treatment of catamenial pneumothorax should include hormonal treatment or surgery by VATS.[24] Some patients with catamenial pneumothorax also develop a hemothorax, resulting in a hemopneumothorax as a complication of their thoracic endometriosis. The blood in the pleural space has typically required a large-bore tube thoracostomy drainage, though hemothoraces can likely be managed with smaller-bore tubes.[83] Because patients with catamenial pneumothoraces are typically young and without underlying parenchymal lung disease, high-concentration oxygen can be administered without fear of hypercapnic respiratory failure.​​

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Choose a patient group to see our recommendations

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

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