RECOGNITION AND ASSESSMENT

Symptoms and signs

  • Sudden onset, occasionally at rest
  • Chest pain (unilateral)
  • Dyspnoea
  • Resonance on percussion with
    • reduced vocal fremitus and
    • reduced breath sounds if moderate-large

Patient in extremis

  • If very dyspnoeic with circulatory compromise, and trachea or mediastinum (apex beat) displaced, consider TENSION PNEUMOTHORAX (very rare)
    • give oxygen (10 L/min) through a high concentration (60–100%) mask
    • insert a large bore cannula of at least 4.5 cm in length into second anterior intercostal space, midclavicular line
    • then insert intercostal tube – see Intercostal tube drainage guideline
    • Remove emergency cannula when bubbling in underwater seal system confirms intercostal tube system functioning

Investigations

  • PA Chest X-ray
    • measure interpleural (rim) distance at level of hilum
  • If findings obscured by surgical emphysema or complex bullous disease, CT scan may help
  • BEWARE: suspected basal pneumothorax usually implies a bulla. CT scan and previous chest X-rays will differentiate bullae from pneumothorax

IMMEDIATE MANAGEMENT

  • If bilateral or haemodynamically unstable, proceed to chest drain. See Intercostal tube drainage guideline
  • Otherwise, follow guidance to help your decision
Guidance tool
Spontaneous PNX Flowchart One

SUBSEQUENT MANAGEMENT

Inpatient observation

  • Admit to a Respiratory ward
  • Administer oxygen – see Oxygen therapy in acutely hypoxaemic patients guideline
  • Inpatient care until stable

Management of intercostal drains

  • Always keep underwater seal below chest
  • Do not clamp chest tube unless advised by pleural team or thoracic surgeon

Repeat Chest X-ray

  • On morning after insertion, repeat Chest X-ray (non-portable)

Result of repeat Chest X-ray

Guidance tool
Spontaneous PNX Flowchart Two

REMOVAL OF CHEST DRAIN

  • If bubbling stopped for at least 24 hr after lung re-inflated on Chest X-ray, remove drain
  • If bubbling through underwater seal recurs in 24 hr after lung re-inflated on Chest X-ray, ask for pleural team opinion

How to remove

  • Cut drain-securing suture
  • Withdraw tube while patient holds breath in expiration
  • If >12 French Gauge drain used, close wound with remaining sutures
  • Repeat Chest X-ray

Recurrent pneumothorax

  • If second or subsequent pneumothorax, restart Immediate management and refer to pleural team

DISCHARGE AND FOLLOW-UP:

  • Arrange pleural clinic appointment in 2–4 weeks
  • Give patient discharge letter and written advice to return immediately if deteriorates
  • No air travel until full lung re-inflation on chest X-ray

© 2022 The Bedside Clinical Guidelines Partnership.

Created by University Hospital North Midlands and Keele University School of Computing and Mathematics.

Research and development team: James Mitchell, Ed de Quincey, Charles Pantin, Naveed Mustfa