← Diagnosis and Management Guides
Pneumothorax
Key considerations: Tension pneumothorax, Open pneumothorax, Hemopneumothorax
Cannot miss
- Tension pneumothorax
- Open pneumothorax
- Hemopneumothorax
Likely diagnoses
- Primary spontaneous pneumothorax
- Secondary spontaneous pneumothorax
- Traumatic pneumothorax
- Iatrogenic pneumothorax
Red flags
- Hypotension
- Tracheal deviation
- Absent breath sounds
- Distended neck veins
Workup
- history: Sudden pleuritic chest pain, dyspnea, trauma, recent procedure, COPD/asthma/CF; exam: Decreased breath sounds, hyperresonance, tracheal deviation (tension); labs: ABG if respiratory distress; imaging: CXR upright (expiratory film may help small PTX); CT chest most sensitive; Ultrasound: absent lung sliding = 95% sensitive; bedside: POCUS: absent lung sliding, absent comet tails, lung point
Management
- immediate: Tension PTX: needle decompression THEN chest tube — clinical diagnosis, do NOT wait for CXR; Large/symptomatic: tube thoracostomy (chest tube); general: Small (<2cm) primary spontaneous PTX in stable patient: observation with repeat CXR in 6hr; Aspiration may be attempted before chest tube in primary spontaneous PTX
Disposition
- admit: All secondary pneumothorax, large pneumothorax, tension PTX, bilateral PTX; discharge: Small primary spontaneous PTX after observation with 6hr repeat CXR stable, with 24-48hr follow-up; consults: Thoracic surgery if recurrent or persistent air leak
Clinical pearls
- Tension pneumothorax is a CLINICAL diagnosis — do not delay decompression for imaging
- Tall thin young males are classic for primary spontaneous PTX
- Recurrence rate after first primary spontaneous PTX is ~30% — flight and diving restrictions
Source and review
- BTS Pneumothorax Guidelines 2010. Last reviewed: 2024-11-01