Spontaneous pneumothoraxMANAGEMENT

RESPIRATORY PRESENTATIONS · 12 SECTIONS

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503 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Acute bronchitis Acute Respiratory Distress Syndrome (ARDS)Acute respiratory failure Apparent Life-Threatening Event (ALTE-BRUE)Aspiration pneumonia Asthma exacerbation Bacterial Tracheitis Bronchiolitis Bronchiolitis (RSV)Chylothorax Community-acquired pneumonia COPD exacerbation COVID-19 pneumonia Croup Croup (laryngotracheobronchitis)Cystic Fibrosis Exacerbation Empyema Epiglottitis Epiglottitis (Pediatric)Fat Embolism Syndrome Foreign Body Aspiration Foreign Body Aspiration (Pediatric)Healthcare-Associated Pneumonia Hemothorax Hospital-acquired pneumonia Legionnaires' Disease Lung Abscess Pertussis Pleural effusion Pleurisy Pneumocystis jirovecii Pneumonia Pneumocystis Pneumonia Pneumomediastinum Pneumothorax (Simple)Pneumothorax (traumatic)Psittacosis Pulmonary Alveolar Proteinosis Pulmonary contusion Pulmonary Edema (Non-cardiogenic)Sarcoidosis Exacerbation Smoke Inhalation Injury Spontaneous pneumothorax Status Asthmaticus Sudden Infant Death Syndrome (SIDS)Tension Pneumothorax Tracheal Stenosis Viral Pneumonia

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp32

Immediate threats

›Life threats

›Tension pneumothorax physiology

›Hypotension or shock

›Severe respiratory distress

›Altered mental status

›Cardiac arrest with PEA pattern

›Immediate actions

›If suspected tension, immediate decompression without imaging

›If cardiac arrest, bilateral finger thoracostomy or needle decompression during CPR

›Monitoring and access

›Continuous SpO2 and ECG

›Noninvasive BP cycling

›Two large bore IV

Oxygenation and ventilation

›Respiratory support

›Oxygen targets

›SpO2 94-98% if no chronic hypercapnia risk

›SpO2 88-92% if COPD with chronic CO2 retention risk

›Ventilation risk mitigation

›Avoid positive pressure ventilation if possible before pleural decompression

›If positive pressure required, immediate chest drain readiness

›Imaging timing

›If unstable, decompression before radiography

Key concepts

›High risk patterns

›Secondary spontaneous pneumothorax

›Underlying lung disease

›Lower physiologic reserve

›Iatrogenic pneumothorax

›Post procedure dyspnea or chest pain

›Higher tension risk with positive pressure ventilation

›Recurrence risk

›Prior pneumothorax history

›Smoking history

02History/hx55

Presentation pattern

›Symptom pattern

›Pleuritic chest pain

›Sudden onset

›Ipsilateral to pneumothorax

›Dyspnea

›Mild in primary spontaneous

›Marked in secondary spontaneous

›Cough

›Nonproductive common

›Hemoptysis atypical

Risk factors and triggers

›Etiology classification

›Primary spontaneous pneumothorax

›Young age

›Tall thin body habitus

›Cigarette smoking

›Cannabis inhalation

›Family history

›Prior episodes

›Secondary spontaneous pneumothorax

›COPD or emphysema

›Asthma

›Cystic fibrosis

›Interstitial lung disease

›Pneumocystis pneumonia

›Lung malignancy

›Tuberculosis

›Necrotizing pneumonia

›Catamenial pneumothorax

›Temporal relationship to menses

›Right sided predominance

›Barotrauma related

›Mechanical ventilation

›Recent scuba diving

›Recent high altitude flight

Red flags and complications

›High acuity clues

›Syncope or presyncope

›Suggests hemodynamic compromise

›Severe chest tightness with wheeze

›Asthma mimic and coexistence

›Fever and infectious symptoms

›Secondary infectious cause consideration

›Connective tissue disorder stigmata

›Marfan phenotype

›Ehlers Danlos phenotype

Key timelines

›Time anchors

›Symptom onset time

›Sudden onset typical

›Progressive dyspnea suggests alternative diagnosis

›Recent procedures

›Central line placement

›Thoracentesis

›Lung biopsy

›Recent trauma

›Blunt chest trauma

›Penetrating injury

03Physical Exam/exam42

Initial assessment

›Vital sign pattern

›Tachycardia

›Common early finding

›Out of proportion tachycardia suggests tension or PE

›Tachypnea

›Increased work of breathing

›Accessory muscle use

›Hypotension

›Tension pneumothorax concern

›Alternative shock etiologies consideration

›Hypoxemia

›More likely in secondary spontaneous

›Severity correlates with physiologic reserve

Chest exam

›Respiratory exam

›Unilateral decreased breath sounds

›Higher specificity than sensitivity

›Subtle in small pneumothorax

›Hyperresonance to percussion

›Variable sensitivity

›Hard to assess in noisy environments

›Decreased tactile fremitus

›Suggests air in pleural space

›Tracheal deviation

›Late sign of tension

›Not required for diagnosis

›Subcutaneous emphysema

›Palpable crepitus

›Suggests pleural air leak

Tension physiology indicators

›Hemodynamic compromise

›Jugular venous distension

›May be absent with hypovolemia

›Narrow pulse pressure

›Progressive obstructive shock

›Cyanosis

›Late sign

PITFALLS

›Miss risks

›Normal breath sounds with small apical pneumothorax

›Reliance on imaging or ultrasound

›Wheeze dominating exam

›Asthma coexistence

›Obesity and loud environments

›Reduced auscultation reliability

04Differential Diagnosis/ddx41

Life threats to exclude

›High risk diagnoses

›Pulmonary embolism (ICD-10 I26.-)

›Pleuritic pain with tachycardia

›Risk factors for venous thromboembolism

›Acute coronary syndrome (ICD-10 I21.-, I24.-)

›Pressure like pain

›Risk factors for CAD

›Aortic dissection (ICD-10 I71.0)

›Tearing pain

›Pulse deficit

›Pericardial tamponade (ICD-10 I31.4)

›Beck triad pattern

›Pulsus paradoxus

›Severe asthma (ICD-10 J45.-)

›Silent chest

›Hypercapnia risk

›Pneumonia with sepsis (ICD-10 J18.-, A41.-)

›Fever

›Focal crackles

Mimics and related causes

›Alternative diagnoses

›Pleural effusion (ICD-10 J90)

›Dullness to percussion

›Reduced breath sounds basally

›Rib fracture (ICD-10 S22.3-)

›Focal tenderness

›Trauma history

›Costochondritis (ICD-10 M94.0)

›Reproducible chest wall pain

›Esophageal rupture (ICD-10 K22.3)

›Severe vomiting

›Mediastinal emphysema concern

›Panic or anxiety syndrome (ICD-10 F41.-)

›Paresthesias

›Normal lung exam and imaging

Coding and standard terms

›Pneumothorax terms

›Spontaneous pneumothorax (ICD-10 J93.11)

›Primary spontaneous pneumothorax SNOMED CT concept

›Secondary spontaneous pneumothorax (ICD-10 J93.12)

›Underlying lung disease association

›Traumatic pneumothorax (ICD-10 S27.0-)

›Injury related pleural air

05Laboratory Tests/lt24

Initial tests by severity

›Targeted labs

›Venous blood gas if respiratory compromise

›pH assessment

›PCO2 trend in mmHg

›Arterial blood gas if severe hypoxemia or ventilated

›PaO2 in mmHg

›PaCO2 in mmHg

›Complete blood count if infection concern

›Leukocytosis context

›Hemoglobin baseline if procedure planned

›Electrolytes and creatinine if admission or procedural sedation

›Renal function for CT contrast planning

›Potassium and magnesium for arrhythmia risk

Pre procedure and complication screening

›Safety labs

›Coagulation studies if anticoagulated or liver disease

›INR guidance for invasive drainage

›Platelets threshold context

›Type and screen if large bore chest tube or operative plan

›Procedural bleeding contingency

PITFALLS and limitations

›Test limitations

›Normal gases with small pneumothorax

›Clinical and imaging correlation

›Troponin elevation not pneumothorax specific

›Concurrent demand ischemia possibility

06Diagnostic Tests/dt58

Scoring Systems

›Decision support

›No universally accepted ED scoring system for spontaneous pneumothorax severity

›Stability assessment drives pathway

›Size estimation guides intervention selection

›Clinical stability criteria

›Hemodynamic stability

›SBP maintained without vasopressors

›No shock signs

›Respiratory stability

›SpO2 maintained on minimal oxygen

›No impending fatigue

›Functional reserve

›Secondary pneumothorax higher risk category

MRI

›MRI role

›Limited acute role

›Poor availability in unstable patient

›Not first line for pleural air

›Problem solving indications

›Complex pleural pathology evaluation

›Radiation avoidance in select recurrent cases

›CT role

›Indications

›Unclear diagnosis after CXR and ultrasound

›Suspected underlying bullous disease

›Persistent air leak

›Suspected secondary cause

›Strengths

›Highest sensitivity for small pneumothorax

›Detection of blebs and bullae

›Limitations

›Radiation exposure

›Transport risk in unstable patient

Ultrasound (or US)

›POCUS for pneumothorax

›Key signs

›Lung sliding absent

›Suggests pneumothorax in correct context

›Alternative causes include apnea and pleurodesis

›B lines present

›Pneumothorax unlikely at scanned location

›Lung point present

›High specificity for pneumothorax

›Size approximation by location

›M mode patterns

›Seashore sign normal sliding

›Barcode sign absent sliding

›Tension adjuncts

›IVC dilation with reduced collapse

›Right heart strain not typical for isolated pneumothorax

Chest radiography

›Radiography approach

›Upright PA and lateral preferred when feasible

›Visceral pleural line identification

›Apical pneumothorax detection

›Portable AP limitations

›Small pneumothorax under detected

›Supine deep sulcus sign

›Expiratory films

›Not routinely required

›Consider if suspicion high and initial film equivocal

07Disposition/dispo40

Level of care

›Admission criteria

›Secondary spontaneous pneumothorax

›Higher complication risk

›Lower threshold for inpatient management

›Persistent symptoms after initial management

›Ongoing dyspnea

›Recurrent pain requiring parenteral analgesia

›Need for pleural intervention

›Chest tube in place

›Ongoing air leak

›Large pneumothorax with limited follow up reliability

›Social barriers

›Remote residence

›ICU or monitored bed criteria

›Tension physiology or recent decompression

›Hemodynamic instability resolved but high risk

›Positive pressure ventilation required

›Barotrauma progression risk

›Significant hypoxemia

›High flow oxygen requirement

Discharge criteria

›Outpatient pathway criteria

›Primary spontaneous pneumothorax

›Hemodynamic stability

›Minimal dyspnea at rest

›Post observation stability

›Repeat imaging stable or improving

›Pain controlled with oral regimen

›Follow up plan confirmed

›Clear return precautions

›Repeat imaging timing arranged

Consultation and transfer

›Specialty involvement

›Thoracic surgery or pulmonology

›Persistent air leak beyond 48-72 hours

›Recurrent ipsilateral pneumothorax

›Bilateral pneumothorax

›Hemopneumothorax

›Significant bullous disease

›Interfacility transfer

›Need for surgical intervention without local capacity

›Ongoing instability despite drainage

08Treatment/t112

Initial supportive care

›Support bundle

›Oxygen therapy

›High concentration oxygen for nitrogen washout

›Consider if hypoxemic

›Consider if symptomatic small pneumothorax

›COPD hypercapnia risk strategy

›Target SpO2 88-92%

›Blood gas monitoring if worsening somnolence

›Activity restriction

›Bed rest during acute symptoms

›Avoid Valsalva type strain

Analgesia

›Pain control

›Acetaminophen

›15 mg/kg PO up to 1000 mg per dose

›Maximum 4000 mg per day

›Lower maximum in liver disease

›Ibuprofen

›10 mg/kg PO up to 600 mg per dose

›Maximum 2400 mg per day

›Avoid in renal injury or GI bleed risk

›Morphine

›0.05-0.1 mg/kg IV

›Titrate every 5-10 minutes to effect

›Monitor respiratory rate and sedation

›Fentanyl

›0.5-1 mcg/kg IV

›Repeat every 5 minutes to effect

›Short duration advantage for procedures

Needle decompression and finger thoracostomy

›Emergency decompression

›Indications

›Suspected tension pneumothorax

›Decompression before imaging

›Clinical diagnosis priority

›Needle decompression sites

›2nd intercostal space midclavicular line

›Higher failure with chest wall thickness

›Longer catheter preferred

›4th or 5th intercostal space anterior or midaxillary line

›Often higher success rate

›Avoid neurovascular bundle along inferior rib margin

›Finger thoracostomy

›Preferred in arrest or peri arrest with trained operator

›Immediate pleural entry confirmation

›Bridge to chest drain

Conservative management and observation

›Observation strategy

›Small primary spontaneous pneumothorax with minimal symptoms

›Observation in ED setting

›Repeat CXR after 4-6 hours

›Discharge after stability

›Stable imaging

›Stable symptoms

Needle aspiration

›Aspiration pathway

›Appropriate candidates

›Primary spontaneous pneumothorax

›Moderate to large size

›Hemodynamically stable

›Technique elements

›Small catheter in 2nd intercostal space or safe triangle

›Stop when resistance or symptom improvement

›Stop if air volume large without improvement

›Post aspiration reassessment

›Repeat CXR

›If residual large pneumothorax, proceed to chest tube

Chest tube and pleural catheter

›Pleural drainage

›Indications

›Secondary spontaneous pneumothorax with symptoms

›Lower threshold for drainage

›Admission typical

›Failed needle aspiration

›Persistent large pneumothorax

›Ongoing dyspnea

›Hemodynamic instability after initial decompression

›Definitive tube placement

›Positive pressure ventilation requirement

›Prevent progression to tension

›Tube size selection

›Small bore catheter 8-14 Fr

›Primary spontaneous pneumothorax often adequate

›Less pain and easier insertion

›Larger bore 20-28 Fr

›Hemopneumothorax

›Thick pleural fluid coexistence

›Drain management

›Water seal initial

›Avoid routine suction at insertion

›Reduce reexpansion pulmonary edema risk

›Suction strategy

›If lung fails to reexpand

›If persistent air leak with large pneumothorax

›Antibiotics

›Not routine for spontaneous pneumothorax chest tube

›Consider if traumatic component or empyema risk

Definitive prevention strategies

›Recurrence prevention

›Smoking cessation

›Strongest modifiable risk factor

›Counseling and pharmacotherapy options

›Pleurodesis consideration

›Recurrent ipsilateral pneumothorax

›First contralateral pneumothorax

›Persistent air leak

›High risk occupations

›Surgical options

›VATS blebectomy and pleurodesis

›Lower recurrence than conservative care

›Post op follow up required

Evidence and recommendation levels

›Guideline aligned statements

›Stable suspected tension pneumothorax

›Immediate decompression as Class I recommendation based on expert consensus

›Primary spontaneous pneumothorax

›Needle aspiration as Class IIa recommendation in stable patients based on guideline consensus

›Secondary spontaneous pneumothorax

›Chest drainage favored as Class IIa recommendation due to higher failure of aspiration

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Maternal physiology

›Reduced functional residual capacity

›Lower tolerance of hypoxemia

›Imaging approach

›CXR acceptable with shielding

›Ultrasound preferred adjunct when available

›Treatment thresholds

›Lower threshold for drainage if symptomatic

›Multidisciplinary involvement with obstetrics

Geriatric

›Older adult considerations

›Secondary causes prevalence

›COPD and malignancy higher likelihood

›Lower physiologic reserve

›Analgesia risk

›Opioid sensitivity

›Delirium risk

›Disposition bias

›Lower threshold for admission

›Early specialty consultation

Pediatrics

›Pediatric considerations

›Etiology

›Primary spontaneous in adolescents

›Secondary causes include asthma and cystic fibrosis

›Weight based dosing

›Analgesics and sedation weight based calculations

›Tube size selection by size and age

›Disposition

›Pediatric center involvement when available

›Family education and return precautions emphasis

10Background/b34

Epidemiology

›Population patterns

›Primary spontaneous pneumothorax demographics

›Most common in adolescents and young adults

›Male predominance

›Smoking association

›Increased risk compared with nonsmokers

›Recurrence risk increased with continued smoking

›Recurrence

›Highest within first year after initial episode

›Increased with prior episodes

Pathophysiology

›Mechanisms

›Pleural air entry

›Rupture of subpleural blebs

›Alveolar pleural fistula

›Secondary spontaneous drivers

›Diseased lung tissue fragility

›Air trapping and bullae

›Tension physiology

›One way valve effect

›Increased intrathoracic pressure

›Reduced venous return and obstructive shock

Therapeutic Considerations

›Management rationale

›Oxygen therapy concept

›Increased pleural nitrogen gradient

›Potential faster pleural air resorption

›Aspiration versus tube

›Aspiration less invasive

›Higher failure in secondary pneumothorax

›Suction strategy

›Not routine at insertion

›Consider for incomplete reexpansion

›Prevention strategy

›Smoking cessation reduces recurrence risk

›Pleurodesis reduces recurrence in selected patients

11Patient Discharge Instructions/pdi21

copy discharge instructions

›Home care and follow up

›Activity and travel restrictions

›No air travel until full radiographic resolution confirmed

›No scuba diving unless definitive pleurodesis and specialist clearance

›Avoid heavy lifting and strenuous exercise until cleared

›Medications

›Use prescribed pain medicines as directed

›Avoid sedatives or alcohol with opioids

›Follow up plan

›Repeat chest imaging within 24-72 hours if managed without tube

›Specialty follow up if recurrent episode or secondary cause suspected

›Risk reduction

›Smoking cessation support

›Avoid inhaled cannabis or vaping

›Return to ED immediately

›Worsening shortness of breath

›New chest pain or rapidly increasing pain

›Fainting or near fainting

›Blue lips or severe weakness

›Fever with worsening cough

›Palpitations with dizziness

12References/r14

Clinical guidelines and core sources

›Reference set

›British Thoracic Society guideline framework for spontaneous pneumothorax management

›Primary spontaneous pneumothorax pathways

›Secondary spontaneous pneumothorax pathways

›American College of Chest Physicians consensus statements for pneumothorax

›Aspiration versus tube guidance

›Recurrence prevention strategies

Evidence based sources

›Evidence anchors

›Trials and observational studies comparing needle aspiration versus chest tube in primary spontaneous pneumothorax

›Similar initial success in selected stable cases

›Failure rates higher in secondary spontaneous pneumothorax

›Ultrasound diagnostic accuracy literature for pneumothorax

›Lung point high specificity

›Absence of lung sliding context dependent

Learn More: Spontaneous pneumothorax→

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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