Management of Pneumothorax


Pneumothorax is defined as air in the pleural space. Primary spontaneous pneumothoraces arise in otherwise healthy people without any lung disease, secondary spontaneous pneumothoraces in patients with underlying lung disease.

Assessment / monitoring

  • CXR (expiratory CXR is not routinely required for the diagnosis of pneumothorax)
  • CT scanning is recommended when:
    • Differentiating a pneumothorax from complex bullous lung disease.
    • Pneumothorax may be complex and drain placement difficult e.g. partial adherence of lung to chest wall.
    • Incorrect tube placement is suspected.
    • Plain chest radiograph is obscured by surgical emphysema.

General management

  • The flow diagram above for primary and secondary pneumothoraces provides a systematic approach to treatment decisions.
  • Aspiration can often be effective in primary spontaneous pneumothorax and should be considered prior to chest drain insertion.
  • There is no evidence that large chest drains are more effective except in trauma. Smaller drains (e.g. ≤ 16 Fr) are easier to insert and better tolerated by the patient.
  • Patients with chest drains should be managed in a ward used to dealing with them (e.g. respiratory ward) to minimise complications.

Treatment options

  • Further treatment options include chest drain suction, pleurodesis and thoracic surgery. If a pneumothorax fails to respond to treatment within 48 hours, prompt referral to a respiratory physician is essential so that these options may be considered.
  • Persons with a recurrent pneumothorax should be referred for a respiratory opinion as pleurodesis and investigation for underlying lung disease is indicated.
  • Patients should be advised that they should not fly until the pneumothorax has resolved radiologically and for 1 week afterwards. They should further be advised to seek specialist medical advice prior to scuba-diving as this may be permanently contraindicated unless surgical bilateral pleurectomy is undertaken.
  • Strong emphasis should be placed on the relationship between the recurrence of pneumothorax and smoking in an effort to encourage patients to stop smoking.

Guideline last reviewed February 2021