Pneumothorax

Pneumothorax is an accumulation of air or gas in the pleural space, leading to lung collapse.

• Spontaneous pneumothorax: occurs without trauma or an obvious trigger.
  • High-risk characteristics: haemodynamic compromise, significant hypoxia, bilateral pneumothorax, underlying lung disease, ≥50 years with significant smoking history, haemopneumothorax.
  • No high-risk characteristics.
• Traumatic pneumothorax: result of blunt or penetrating injury.
• Tension pneumothorax: air enters but cannot exit the pleural space, leading to increasing intrathoracic pressure (medical emergency).
• Iatrogenic pneumothorax: result of medical procedures, e.g. central line insertion, lung biopsy.

• Sudden onset of pleuritic chest pain.
• Dyspnoea.

• On affected side:
  • Reduced chest expansion.
  • Hyperresonance to percussion.
  • Decreased breath sounds.
• In tension pneumothorax: severe respiratory distress, tracheal deviation away from affected side, distended neck veins, hypotension.

• Chest X-ray: shows absence of lung markings peripherally and a visible pleural line.
• CT scan: useful if it is unclear whether it is safe to intervene, it is a complicated pneumothorax, the diagnosis is uncertain, or to evaluate for underlying lung disease.

• High risk characteristics present → chest drain (a tension pneumothorax will require needle thoracostomy to stabilise the patient first).
• No high risk characteristics present → multiple options depending on patient priorities:
  • Observation with serial CXRs.
  • Ambulatory pleural device.
  • Needle aspiration.
  • Chest drain.
• Surgical intervention: may be required in recurrent cases or persistent cases, most commonly by video-assisted thoracoscopic surgery (VATS).

Air travel must be avoided for at least 2 weeks after successful full lung re-expansion.

• Recurrent pneumothorax.
• Respiratory failure: In cases of bilateral pneumothoraces or in patients with compromised lung function.
• Haemothorax: If blood vessels are damaged or iatrogenic related to chest drain insertion.

• Pneumothorax is an accumulation of air or gas in the pleural space, leading to lung collapse.
• There are multiple types (e.g., spontaneous, traumatic, tension) which differ in severity.
• Early recognition and intervention are crucial to prevent life-threatening complications.
• Diagnosis is defined primarily through chest X-ray showing characteristic findings.
• Management varies dependent on the patient’s risk status, consisting of observation, chest draining and surgery if required.

British Thoracic Society ‘Guideline for Pleural Disease’ 2023.