Air accumulating in pleural space:

• Primary spontaneous pneumothorax (PSP)
  
  • aged <50 yr, absence of suspected lung disease
• Secondary spontaneous pneumothorax (SSP)
  
  • aged ≥50 yr or significant smoking history or evidence of chronic lung disease on history, examination or CXR

Symptoms and signs

• Sudden onset, occasionally insidious: 
  
  • chest pain (unilateral)
  • breathlessness
• Resonance on percussion, with reduced vocal fremitus and breath sounds (if significant)
• Establish if chronic lung disease (SSP) and identify presence of high risk characteristics

High risk characteristics

• Haemodynamic compromise (tension pneumothorax)
• Significant hypoxia
• Bilateral pneumothoraces
• Underlying lung disease
• Aged >50 yr with significant smoking history
• Haemopneumothorax

Investigations

• PA chest X-ray - to help determine degree of lung collapse
• In patients with complex bullous disease and partially pleurodesed lung or if lungs are obscured by surgical emphysema, consider plain CT chest before invasive pleural interventions

Follow Pneumothorax management pathway

¹ Safe to intervene

• It is safe to intervene if ≥2 cm rim from apex or lateral chest wall on chest X-ray

² Conservative care

• For minimally symptomatic (i.e no significant pain or breathlessness and with no physiological compromise) or asymptomatic PSP, regardless of size of lung collapse
• PSP: discharge and refer to pleural clinic (call 75353) or respiratory team for regular follow-up within 1-2 days and then every 2-4 days until stable, and every 2-4 weeks thereafter
  
  • if pneumothorax or symptoms increasing, admit and insert chest drain - see Intercostal tube drainage guideline
  • if outpatient pleural service not available, discuss with respiratory team
• SSP: admit and monitor as inpatient
  
  • discharge when stable, with follow-up in pleural clinic (call 75353) or respiratory outpatients in 2-4 days with further follow-up until lung fully reinflated
  • if pneumothorax or symptoms increasing, admit and insert chest drain - see Intercostal tube drainage guideline

³ Ambulatory one-way valve device

• Refer to pleural team (call 75353) for device insertion
• Follow-up every 2-4 days
• Remove device once lung almost fully inflated and further follow-up as required
  
  • if pneumothorax or symptoms increasing, admit and insert chest drain - see Intercostal tube drainage guideline

⁴ Needle aspiration

• See Pleural aspiration of air guideline
• If resolved, discharge and follow-up in pleural clinic (call 75353) or respiratory outpatients in 2-4 weeks 
  
  • if unresolved or patient still symptomatic and >2.5 L of air aspirated on first attempt, proceed with chest drain insertion - see Intercostal tube drainage guideline

⁵ Specialist review

• Discuss with radiology if safe to insert chest drain - see Intercostal tube drainage guideline or if CT guided procedure required
• If not possible to insert chest drain refer to pleural team (call 75353) or respiratory team

⁶ Chest drain

• See Intercostal tube drainage guideline
• Refer to pleural team (call 75353)
• If recurrent pneumothorax or first episode in high risk patient in whom recurrence could be life-threatening, discuss with thoracic surgeons
• Refer for consideration of acute thorax surgery if
  
  • presenting with tension pneumothorax
  • high risk occupation (e.g. airline pilot, diver)

Review

• Ensure drain is swinging at all times
• Always keep underwater seal bottle below waist level
• Do not clamp chest tube unless advised by pleural team or thoracic surgeon
• Consider chest X-ray - if lung not re-inflated and not bubbling in underwater bottle
• Try to remove block or kink - if unsuccessful, contact pleural team 

Non-resolution

• Refer to pleural or respiratory team (call 75353)
• Failure to reinflate - possible causes include: 
  
  • persistent air-leak
  • displaced/blocked tube
  • broncho-pleural fistula
  • underlying lung disease
• Use high volume/low pressure suction, starting at -1.0 to -2.0 kPa (-10 to -20 cm H₂O) as tolerated
• Early discussion with thoracic surgeons, refer if:
  
  • pneumothorax fails to resolve after 5 days of above management or 
  • after 3 days if patient has chronic lung disease
• Patients with secondary spontaneous pneumothorax that are unfit for surgery consider:
  
  • medical pleurodesis (see Medical pleurodesis guideline)
  • ambulatory management with a one-way valves devices (Heimlich valve/flutter bag etc.) and digital drain with close follow-up in the pleural clinic

Removal

• Bubbling stopped for ≥24 hr after complete or almost complete lung re-inflation
• Cut drain-securing suture and withdraw tube while patient holds breath in expiration
• Close wound with sutures and reapply dressing

• Refer all patients with spontaneous pneumothorax to pleural or respiratory team (call 75353) for appropriate follow up as detailed above
• Refer to cardiothoracic outpatients for consideration of elective surgery to prevent recurrence if:
  
  • at risk profession, e.g. diver, airline pilot or in military
  • second ipsilateral or first contralateral pneumothorax
  • tension pneumothorax