Pneumothorax

Definition & Classification

• Pneumothorax: Air in the pleural space.

• Primary Spontaneous: No underlying lung disease.

• Secondary Spontaneous: Involves underlying lung disease (eg COPD, asthma, ILD, cystic fibrosis).

• Traumatic: Blunt/penetrating chest injury or iatrogenic (procedural).

• Decompensated (Tension): Rapid onset, unstable patient (hypotension, severe dyspnoea); requires urgent needle decompression.

Clinical Clues

• Presentation: Sudden pleuritic chest pain + breathlessness.

• Signs (large pneumothorax): Absent breath sounds, hyperresonance on percussion, possible tracheal deviation away from the affected side.

• Diagnosed: Primarily via upright inspiratory chest X‐ray (CT if needed).

Decompensated (Tension) Pneumothorax

• Emergency: Immediate needle decompression (above 3rd rib, midclavicular line), then chest tube.

• Rare in primary spontaneous pneumothorax but more common in secondary disease or trauma.

• Suspect in any unstable patient, especially on positive‐pressure ventilation.

Primary Spontaneous Pneumothorax

• Many are not dangerous and can resolve spontaneously in stable patients.

• Conservative management often sufficient if patient is stable (analgesia ± oxygen if hypoxaemic).

• Catheter aspiration or intercostal drain if large or patient unstable.

• Recurrence ~30–50%. Smoking cessation reduces recurrence. Second ipsilateral episode → consider pleurodesis.

Secondary Spontaneous Pneumothorax

• Underlying lung disease → more severe, even if small.

• More likely to require early intervention (eg intercostal drain).

• Do not use non‐invasive ventilation (CPAP/BPAP) unless the pneumothorax is definitively drained.

Traumatic & Iatrogenic Pneumothorax

• Traumatic: Usually chest tube if large/unstable; consider larger‐bore tube if blood is present.

• Iatrogenic: Often small; manage conservatively if stable, or aspirate if needed.

Persistent Air Leak

• Common with intercostal drains; many resolve within ~14 days without surgery.

• Small‐bore catheter with a one‐way valve (Heimlich) can facilitate outpatient management if stable.