Pneumothorax Summary

Types

  • PSP: No underlying lung disease
  • SSP: With underlying lung disease
  • Tension: Medical emergency

Risk Factors

  • Tall, thin males (PSP)
  • Smoking
  • COPD (most common SSP)
  • Marfan's, Ehlers-Danlos syndromes

Clinical Features

  • Dyspnea, chest pain, tachypnea
  • Reduced air entry, hyperresonance
  • PSP: Mild symptoms, often delayed presentation
  • SSP: More severe symptoms

Investigations

  • CXR: Erect PA view in inspiration
  • Visible visceral pleural edge
  • Absent peripheral lung markings
  • CT: Gold standard for small PTX

Management (BTS 2023)

  • Asymptomatic: Conservative care
  • Symptomatic + high risk: Chest drain
  • Symptomatic + low risk: Conservative/ambulatory/aspiration
  • Intervention for ≥2cm on CXR or any size on CT

High Risk Features

  • Hemodynamic compromise
  • Significant hypoxia
  • Bilateral pneumothorax
  • Underlying lung disease
  • >50 years + smoking history
  • Hemopneumothorax

Discharge Advice

  • Return if increasing breathlessness
  • No air travel for ≥1 week after resolution
  • Permanent diving restriction (exceptions apply)
  • Smoking cessation

Spontaneous Pneumothorax

Air in the pleural space without trauma or medical intervention

Definitions

Primary Spontaneous Pneumothorax (PSP)

  • Occurs without suspected lung disease
  • Most have emphysema-like changes on CT
  • Different management and outcomes from SSP

Secondary Spontaneous Pneumothorax (SSP)

  • Occurs with underlying lung disease
  • Consider secondary if >50 years with smoking history
  • Associated with:
    • COPD (most common)
    • TB, asthma, pneumonia
    • Sarcoidosis, cystic fibrosis
    • Malignancy, bronchiectasis
    • Pulmonary fibrosis, AIDS

Risk Factors

Primary Spontaneous Pneumothorax

  • Tall, thin males
  • Marfan's syndrome
  • Ehlers-Danlos syndrome
  • Alpha-1 antitrypsin deficiency
  • Smoking

Clinical Features

Symptoms

  • Dyspnea
  • Tachypnea
  • Chest pain

Signs

  • Reduced expansion on affected side
  • Reduced air entry
  • Hyperresonance to percussion
  • Reduced vocal/tactile fremitus

Key Differences

  • PSP: Symptoms mild, often present >2 days after onset
  • SSP: More severe symptoms due to pre-existing lung disease
  • Tension pneumothorax: Consider if severe symptoms + cardiorespiratory distress

Investigations

Chest X-ray

  • Erect PA view in inspiration
  • Findings:
    • Visible visceral pleural edge (thin white line)
    • Absent lung markings peripherally
    • Radiolucent peripheral space
    • Small pleural effusions sometimes seen

CT Scanning

  • Gold standard for small pneumothoraces
  • Useful for:
    • Surgical emphysema
    • Bullous lung disease
    • Aberrant chest drain placement
    • Additional lung pathology

Arterial Blood Gas

  • Not needed if SpO2 >92% on room air
  • 75% have PaO2 <10.9 kPa

Management (BTS 2023 Pathway)

Initial Assessment

Is the patient symptomatic?

  • No:
    • Conservative care
    • PSP: Outpatient review every 2-4 days
    • SSP: Inpatient review
    • If stable: OPD follow-up in 2-4 weeks
  • Yes: Assess for high risk characteristics:
    • Hemodynamic compromise (tension)
    • Significant hypoxia
    • Bilateral pneumothorax
    • Underlying lung disease
    • >50 years + smoking history
    • Hemopneumothorax

High Risk Characteristics Present?

  • Yes + unsafe to intervene: CT imaging and reassess
  • Yes + safe to intervene:
    • Chest drain
    • Inpatient review
    • Remove drain when resolved
    • Consider talc pleurodesis for first episode in high-risk patients
    • OPD follow-up in 2-4 weeks
  • No + unsafe to intervene: Conservative care
  • No + safe to intervene: Consider (patient preference/local availability):
    • Conservative care OR
    • Ambulatory device + outpatient review every 2-3 days OR
    • Needle aspiration
    • If not resolved → chest drain

Note: Intervention usually considered for ≥2cm laterally/apically on CXR or any size on CT that can be safely accessed

Discharge and Follow-up

Patient Advice

  • Return if increasing breathlessness develops
  • Respiratory specialist follow-up until full resolution
  • Avoid air travel for ≥1 week after confirmed resolution
  • Permanent diving restriction (unless bilateral surgical pleurectomy with normal post-op lung function/CT)
  • Smoking cessation (reduces recurrence risk)