Pneumothorax: Management

Key points

• Primary spontaneous pneumothorax (PSP): no underlying lung disease; secondary (SSP): underlying lung disease. Tension pneumothorax is a clinical emergency — needle decompression immediately, do not wait for imaging.
• BTS 2023 uses a SYMPTOM-based approach (not size alone): minimally symptomatic or asymptomatic PSP (no significant pain/breathlessness, no physiological compromise) → conservative management, regardless of size.
• PSP needing treatment: ambulatory management (ambulatory device) is preferred where support and expertise exist; otherwise needle aspiration or a chest drain. High-risk features (marked breathlessness, hypoxia, bilateral, haemodynamic compromise) → intervene.
• Secondary spontaneous pneumothorax: lower threshold to admit and drain (chest drain, especially if over 50, large or breathless) with high-flow oxygen; consider chemical pleurodesis/thoracic surgery to prevent recurrence.
• Advise smoking cessation — the lifetime risk in healthy smoking men is about 10% vs 0.1% in non-smokers. Refer for surgery (VATS pleurectomy/pleurodesis) after recurrence or persistent air leak.

Decision points in this pathway

• Primary or secondary (underlying lung disease)?
• Age > 50 AND rim > 2 cm and/or breathless?
• Rim < 2 cm and NOT breathless?
• Aspiration fails (> 2 cm or still breathless)?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.