A primary spontaneous pneumothorax occurs in young people without known respiratory illnesses. A secondary spontaneous pneumothorax occurs in patients with pre-existing pulmonary diseases.
A tension pneumothorax is a medical emergency that requires immediate decompression.
Patients with a pneumothorax typically report dyspnoea and chest pain. In tension pneumothorax, patients are distressed with rapid laboured respirations, cyanosis, profuse diaphoresis, and tachycardia.
First-line treatment of pneumothoraces depends on a combination of clinical features, and size/type of pneumothorax. It may include observation with supplemental oxygen therapy, percutaneous aspiration of the air in the pleural space, insertion of a chest drain, and in some patients video-assisted thoracoscopy (VATS) or thoracostomy.
Patients with spontaneous pneumothoraces are at risk for recurrence. Pleurodesis (either by mechanical abrasion or by chemical irritation of pleural surfaces) is used to limit the likelihood of recurrence.
Pneumothorax occurs when air gains access to, and accumulates in, the pleural space.
History and exam
Key diagnostic factors
- chest pain
- ipsilateral reduced breath sounds
- ipsilateral hyperinflation of the hemithorax with hyper-resonance on percussion
- presence of risk factors
- cardiopulmonary deterioration
- trachea shifted to the contralateral side
Other diagnostic factors
- cigarette smoking
- family history of pneumothorax
- tall and slender body build
- age <40 years
- recent invasive medical procedure
- chest trauma
- acute severe asthma
- AIDS-related Pneumocystis jirovecii infection
- cystic fibrosis
- Marfan syndrome
- primary lung cancer and metastatic cancer to the lungs
- Birt-Hogg-Dube syndrome
- pulmonary Langerhans cell histiocytosis
- Erdheim-Chester disease
1st investigations to order
- chest x-ray
- blood tests
Investigations to consider
- chest ultrasound
- CT chest
- arterial blood gas (ABG)
suspected tension pneumothorax
confirmed primary spontaneous pneumothorax
confirmed secondary spontaneous pneumothorax
confirmed traumatic non-tension pneumothorax
confirmed pneumothorax ex vacuo
acute pneumothorax resolved
Jonathan Bennett, MD
Honorary Professor of Respiratory Sciences
University of Leicester
JB is Chair of the British Thoracic Society (BTS). He is also deputy medical director RCP Invited service Reviews, and speaker at National Society (eg., BTS), Primary Care respiratory Society, Society Cardiothoracic Surgeons meetings.
JB declares that he has no competing interests.
Claire Vella, MD, MRCP
Clinical Fellow Lung Cancer and Interventional Pulmonology
CV declares that she has no competing interests.
University Hospitals of Leicester NHS Trust
OU declares that she has no competing interests.
BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:
Lonny Yarmus, DO, MBA
Associate Professor of Medicine and Oncology
Clinical Director, Division of Pulmonary and Critical Care
Director, Interventional Pulmonology Research Core
Johns Hopkins Medical Institutions
Jason Akulian, MD, MPH
Assistant Professor of Medicine
Director, Interventional Pulmonology
Carolina Center for Pleural Disease
University of North Carolina
LY has received research grants and consulting fees from Olympus, Inc, the manufacturer of the Spiration intrabronchial valve. JA declares that he has no competing interests.
Matthew Knight, PGCertEd MD FRCP FRCP(Edin)
Associate Postgraduate Dean
Health Education England
Royal College of Physicians College Tutor
Consultant Respiratory Physician
Watford General Hospital
West Hertfordshire Hospitals NHS Trust
MK was collaborator and site principal investigator for the randomised ambulatory management of primary pneumothorax (RAMPP) trial, which received funding from Rocket Medical. MK has attended meetings sponsored by Rocket Medical.
Section Editor, BMJ Best Practice
AS declares that she has no competing interests.
Head of Editorial, BMJ Best Practice
AE declares that she has no competing interests.
Lead Section Editor, BMJ Best Practice
RW declares that she has no competing interests.
Comorbidities Editor, BMJ Best Practice
JC declares that she has no competing interests.
Drug Editor, BMJ Best Practice
AM declares that he has no competing interests.
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- ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax
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