Pneumothorax

Pneumothorax: air in the pleural space. Primary spontaneous (PSP) — no underlying lung disease, usually tall young males. Secondary (SSP) — underlying disease (COPD, asthma, CF). Tension pneumothorax — air under pressure, haemodynamic compromise…

BTS Pleural Disease Guidelines

The pathway

1 · Identify & classify

Symptoms: sudden pleuritic chest pain, breathlessness
Exam: absent breath sounds, hyper-resonance
CXR: absent lung markings beyond pleural line
PSP vs SSP? Unilateral vs bilateral? Measure rim at hilum on CXR.

2 · Tension pneumothorax

Tracheal deviation away from affected side
absent breath sounds
hypotension
distended neck veins
SpO₂ falling rapidly

DO NOT wait for CXR. Needle decompression with a large-bore cannula: 4th–5th intercostal space, anterior axillary line (the triangle of safety) is now the preferred site — at the older 2nd ICS mid-clavicular line the chest wall is often thicker than a standard cannula is long, so the pleura is missed. Either site is better than delay. Follow immediately with a definitive chest drain — decompression is temporary and can re-tension.

3 · PSP — size decision

Rim <2cm AND breathlessness minimal: discharge with 24h review + safety net
Rim >2cm OR breathless: attempt aspiration

Aspiration: 2nd ICS MCL, 16–18G cannula, 3-way tap, 50ml syringe. Withdraw until resistance — max 2.5L. If successful and <2cm remains: observe 4h, discharge.

4 · SSP management

All SSP require hospital admission and chest drain regardless of size
SSP with small rim in elderly COPD: consider aspiration first
O₂ to SpO₂ 88–92% in COPD (risk of hypercapnic respiratory failure)
Low threshold for respiratory specialist input.

5 · Chest drain insertion

Seldinger drain (8–14Fr) for most pneumothoraces. Safe triangle: anterior axillary fold, 4th–5th ICS. Blunt dissection, advance drain, confirm on CXR. Attach to underwater seal. DO NOT clamp. Monitor for bubbling and lung re-expansion.

6 · Drain management

Swinging = patent
Bubbling = air leak still present
Stop bubbling: lung re-expanded, remove drain after 24h no bubbling
Persistent bubbling >48h → bronchopleural fistula, consider thoracic surgery
Flying: no flying until CXR confirms resolution.

Drugs

Drug	Dose	Route	Notes
High flow O2	15L/min	Non-rebreather mask	Accelerates pleural air reabsorption. Caution in COPD — target SpO₂ 88–92%.
Needle decompression	Large-bore cannula	4th–5th ICS anterior axillary line (or 2nd ICS MCL)	Life-saving in tension pneumothorax. Lateral site preferred — chest wall is thinner. Follow immediately with chest drain.
Lidocaine 1%	5–10ml	Local infiltration	Analgesia for drain insertion. Infiltrate skin, subcutaneous tissue, periosteum.
Morphine	2.5–5mg	IV	Procedural analgesia before drain insertion.

When to escalate

Tension pneumothorax — needle decompression immediately, no time for CXR,Haemodynamic compromise from pneumothorax → immediate drain,Bilateral pneumothoraces → ITU,Persistent air leak >48h → thoracic surgery referral,SSP in COPD/CF/ILD — always admit, low threshold for drain

Reference: BTS Pleural Disease Guidelines 2023 / Resuscitation Council UK

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