Pneumothorax

Last reviewed: 28 Feb 2023

Last updated: 31 Jan 2023

Pneumothorax occurs when air gains access to, and accumulates in, the pleural space.

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.

Definition

Pneumothorax occurs when air gains access to, and accumulates in, the pleural space.[1]

History and exam

Key diagnostic factors

chest pain
dyspnoea
ipsilateral reduced breath sounds
ipsilateral hyperinflation of the hemithorax with hyper-resonance on percussion
hypoxia
presence of risk factors
cardiopulmonary deterioration
trachea shifted to the contralateral side
sweating

Full details

Other diagnostic factors

cough

Full details

Risk factors

cigarette smoking
family history of pneumothorax
tall and slender body build
age <40 years
recent invasive medical procedure
chest trauma
acute severe asthma
COPD
tuberculosis
AIDS-related Pneumocystis jirovecii infection
cystic fibrosis
lymphangioleiomyomatosis
Marfan syndrome
homocystinuria
primary lung cancer and metastatic cancer to the lungs
Birt-Hogg-Dube syndrome
pulmonary Langerhans cell histiocytosis
Erdheim-Chester disease

Full details

Diagnostic investigations

1st investigations to order

chest x-ray
blood tests

Full details

Investigations to consider

chest ultrasound
CT chest
arterial blood gas (ABG)

Full details

Treatment algorithm

INITIAL

suspected tension pneumothorax

ACUTE

confirmed primary spontaneous pneumothorax

confirmed secondary spontaneous pneumothorax

confirmed traumatic non-tension pneumothorax

confirmed pneumothorax ex vacuo

ONGOING

acute pneumothorax resolved

Contributors

Expert advisers

Jonathan Bennett, MD

Honorary Professor of Respiratory Sciences

University of Leicester

Respiratory Consultant

Glenfield Hospital

Leicester

Biography

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.

Disclosures

JB declares that he has no competing interests.

Claire Vella, MD, MRCP

Clinical Fellow Lung Cancer and Interventional Pulmonology

Glenfield Hospital

Leicester

Disclosures

CV declares that she has no competing interests.

Onyeka Umerah

Respiratory Registrar

Glenfield Hospital

University Hospitals of Leicester NHS Trust

Leicester

Disclosures

OU declares that she has no competing interests.

Acknowledgements

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

Baltimore

Jason Akulian, MD, MPH

Assistant Professor of Medicine

Director, Interventional Pulmonology

Carolina Center for Pleural Disease

University of North Carolina

Chapel Hill

Disclosures

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.

Peer reviewers

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

Disclosures

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.

Editors

Annabel Sidwell

Section Editor, BMJ Best Practice

Disclosures

AS declares that she has no competing interests.

Anna Ellis

Head of Editorial, BMJ Best Practice

Disclosures

AE declares that she has no competing interests.

Rachel Wheeler

Lead Section Editor, BMJ Best Practice

Disclosures

RW declares that she has no competing interests.

Julie Costello

Comorbidities Editor, BMJ Best Practice

Disclosures

JC declares that she has no competing interests.

Adam Mitchell

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

Differentials
- Asthma, acute exacerbation
- COPD, acute exacerbation
- Pulmonary embolism
More Differentials
Guidelines
- ACR appropriateness criteria: rib fractures
- ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax
More Guidelines
Videos
Needle decompression of tension pneumothorax animated demonstration
Insertion of intercostal drain, Seldinger technique: animated demonstration
More videos
Patient leaflets
Pneumothorax
More Patient leaflets
Log in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer

Pneumothorax

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

suspected tension pneumothorax

confirmed primary spontaneous pneumothorax

confirmed secondary spontaneous pneumothorax

confirmed traumatic non-tension pneumothorax

confirmed pneumothorax ex vacuo

acute pneumothorax resolved

Contributors

Expert advisers

Jonathan Bennett, MD

Biography

Disclosures

Claire Vella, MD, MRCP

Disclosures

Onyeka Umerah

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Matthew Knight, PGCertEd MD FRCP FRCP(Edin)

Disclosures

Editors

Annabel Sidwell

Disclosures

Anna Ellis

Disclosures

Rachel Wheeler

Disclosures

Julie Costello

Disclosures

Adam Mitchell

Disclosures

Differentials

Guidelines

Videos

Patient leaflets

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice