AKT · Respiratory/Pleura

Pneumothorax

Air in the pleural space — primary (no lung disease), secondary (lung disease), traumatic, or tension

Overview

Air in the pleural space causing partial/complete lung collapse. Primary spontaneous (tall thin young smoker, no lung disease), secondary spontaneous (underlying lung disease — COPD/CF), traumatic/iatrogenic, or tension (a one-way valve causing cardiorespiratory collapse). The BTS 2023 pathway is symptom-based (single algorithm), but the one rule that overrides everything: TENSION pneumothorax is a clinical diagnosis treated with IMMEDIATE decompression — never wait for a CXR.

Recognise

Sudden pleuritic chest pain and breathlessness; reduced breath sounds, hyper-resonant percussion and reduced expansion on the affected side
Primary: tall, thin, young (often smoker), no underlying lung disease; Secondary: COPD/CF/ILD (worse tolerated)
TENSION: severe distress, hypotension/tachycardia, raised JVP, TRACHEAL DEVIATION AWAY from the side — obstructive shock

Red flags

TENSION pneumothorax (haemodynamic compromise, tracheal deviation) → IMMEDIATE needle/finger decompression then chest drain — do NOT wait for imaging
Secondary pneumothorax (underlying lung disease) is poorly tolerated → lower threshold for drainage/admission

Differentials & how to tell them apart

Pleural effusionstony dull (not hyper-resonant), reduced breath sounds

Pulmonary embolism / ACSpleuritic/chest pain without hyper-resonance; different examination/ECG

Large bullacan mimic on CXR — CT distinguishes (avoid draining a bulla)

Pneumothorax — visible lung edge with absent peripheral lung markings (chest X-ray)
Alex Bonilla et al. / CC BY 4.0 — Wikimedia Commons

Investigations

CXR confirms a (non-tension) pneumothorax (visible lung edge, absent lung markings); CT for complex/uncertain cases. Tension is a CLINICAL diagnosis — treat before imaging. Assess for high-risk features (haemodynamic compromise, hypoxia, bilateral, secondary, significant underlying disease).

Management

Tension → immediate decompression; otherwise symptom-based (conservative / aspiration / drain) per BTS 2023

1Is it a TENSION pneumothorax (distress, hypotension, tracheal deviation away, raised JVP)? If so → IMMEDIATE needle/finger decompression then chest drain — do NOT wait for a CXR.Gate: Tension is a clinical diagnosis treated before imaging; for non-tension disease confirm on CXR and use the BTS 2023 symptom-based pathway.
2BTS 2023: minimal symptoms → conservative observation (any size); symptomatic/high-risk → ambulatory device, needle aspiration or chest drain (secondary pneumothorax usually drained/admitted). Smoking cessation; pleurodesis/VATS for recurrence; advise on flying/diving.

Tension → immediate decompression (large-bore cannula 2nd ICS mid-clavicular / 4th–5th ICS anterior axillary, or finger thoracostomy) then chest drain — the can't-wait emergency; oxygen

BTS 2023 symptom-based: minimal symptoms (any size) → conservative observation — asymptomatic/mildly symptomatic primary spontaneous pneumothorax can be observed regardless of size

Symptomatic / high-risk → ambulatory device, needle aspiration, or chest drain — choose by symptoms, support and high-risk characteristics; secondary pneumothorax usually drained/admitted

Smoking cessation; recurrence → pleurodesis/VATS — advise no flying/diving until resolved; surgery for recurrent disease

Key points

Sudden pleuritic pain + breathlessness + HYPER-RESONANT, reduced breath sounds = pneumothorax. TENSION (hypotension + tracheal deviation AWAY + raised JVP) → IMMEDIATE decompression, NEVER wait for a CXR. BTS 2023 is symptom-based: minimal symptoms → conservative (any size); symptomatic/high-risk → aspirate/drain; secondary → drain.

Monitor & prognosis

Resolution on CXR, drain function, recurrence; smoking cessation.

Primary excellent; recurrence common (pleurodesis reduces it); secondary worse (poor reserve).

Source: BTS 2023 pleural disease / pneumothorax