Pneumothorax

Overview

Can be spontaneous, traumatic, or iatrogenic (e.g. related to positive- pressure ventilation).

Spontaneous pneumothorax:

• Primary — no underlying lung disease. Classically young, tall, thin males; secondary to rupture of a pulmonary bleb/air-containing cyst.
• Secondary — underlying lung disease (asthma, COPD, TB, ILD, cystic fibrosis, HIV-associated infection).

Clinical features

Acute shortness of breath and chest pain, typically sharp/stabbing and pleuritic, with tachycardia — classically in a patient with asthma or emphysema (or after inhaling cocaine). Chest examination findings are often absent, but may include hyper-resonance, decreased breath sounds, or tracheal deviation (suggests tension pneumothorax).

Diagnosis

Erect chest X-ray (expiratory films are no longer routinely recommended over standard inspiratory films).

Management

Current approach (primary spontaneous pneumothorax):

• Asymptomatic or mildly symptomatic, clinically stable: conservative/ ambulatory management is the default first-line option, regardless of size — with a repeat CXR after adequate analgesia and observation.
• Significant symptoms, or a large pneumothorax causing breathlessness: consider needle/catheter aspiration as a “conservative intervention” procedure before proceeding to formal intercostal drainage; observe and repeat CXR (e.g. at 2–4 hours) after successful aspiration.
• Drainage (intercostal catheter) remains indicated for persistent/ worsening dyspnoea, failed aspiration, or where conservative management is unsuitable (e.g. bilateral pneumothorax, underlying lung disease, high-risk occupation/travel plans).
• High-flow oxygen (e.g. 10 L/min) may still be given to accelerate reabsorption of air in appropriate patients.

Recurrence: 30–50% after a spontaneous pneumothorax (mostly within the first year). Recurrence on the same side makes further recurrence likely. Recurrent pneumothorax can be managed with pleurodesis (surgical or chemical) or, increasingly, video-assisted thoracoscopic surgery (VATS) with pleurectomy/pleural abrasion, particularly after a second ipsilateral event.

Tension pneumothorax

A medical emergency. Needle decompression: insert a 12–16 gauge needle into the pleural space through the 2nd intercostal space, mid-clavicular line, on the affected side, followed promptly by formal intercostal catheter insertion.