Management of Spontaneous Pneumothorax

Initial Assessment and Treatment

Simple aspiration should be attempted as first-line treatment for spontaneous pneumothorax, followed by chest tube drainage if aspiration fails, as recommended by the British Thoracic Society 1, 2
Determine if the pneumothorax is primary or secondary, and assess clinical stability by evaluating respiratory rate, heart rate, blood pressure, oxygen saturation, and ability to speak in full sentences, according to the American College of Chest Physicians 3, 2
Evaluate the size of the pneumothorax on chest radiograph, with small pneumothoraces being <3 cm apex-to-cupola distance and large pneumothoraces being ≥3 cm, as defined by the American College of Chest Physicians 3
Administer high-flow oxygen (10 L/min) to increase the rate of pneumothorax reabsorption, as recommended by the British Thoracic Society 2, 4

For small primary pneumothorax with minimal symptoms, observation alone may be sufficient, but the patient should be instructed to return if breathlessness develops, as recommended by the British Thoracic Society 2, 5
For symptomatic primary pneumothorax, simple aspiration has a success rate of 59-83%, and repeated aspiration is reasonable if the first attempt fails, according to the British Thoracic Society 2, 4, 7
If aspiration fails, proceed to intercostal tube drainage using a small-bore catheter (≤14F) or moderate-sized chest tube (16F-22F), as recommended by the American College of Chest Physicians 3, 9
For large or secondary pneumothorax, intercostal tube drainage is recommended as initial treatment, using a 16F-22F chest tube for most patients, according to the American College of Chest Physicians 2, 8, 3, 9

Remove the chest tube in a staged manner to ensure the air leak has resolved, and confirm resolution with a chest radiograph after discontinuing any suction, as recommended by the American College of Chest Physicians 3, 9
Advise the patient to avoid air travel until a follow-up chest radiograph confirms complete resolution, and diving should be permanently avoided unless bilateral surgical pleurectomy has been performed, as recommended by the British Thoracic Society 6