Management Guidelines for Spontaneous Pneumothorax

Classification and Size Assessment

Pneumothorax is classified as "small" when there is a visible rim of <2 cm between lung margin and chest wall, and "large" when the rim is >2 cm 2, 3
Primary spontaneous pneumothorax (PSP) occurs in patients without underlying lung disease, while secondary spontaneous pneumothorax (SSP) occurs in patients with underlying lung pathology 1, 3
Plain PA radiograph often underestimates pneumothorax size; CT scanning is the most accurate method for size assessment but is only recommended in complex cases 2, 3

The British Thoracic Society recommends observation alone for small primary pneumothorax (<2 cm) with minimal symptoms 1, 2
The British Thoracic Society recommends observation with hospital admission for small secondary pneumothorax (<1 cm or isolated apical) with minimal symptoms 1
High flow oxygen (10 L/min) should be administered to increase reabsorption rate in patients with small secondary pneumothorax, with caution in COPD patients 2, 3
Simple aspiration is recommended as first-line treatment for primary pneumothorax requiring intervention, with success rates higher in patients under 50 years (70-81%) compared to those over 50 (19-31%) 1, 4, 5
Intercostal tube drainage should be inserted if aspiration fails to control symptoms in any pneumothorax 4, 6
Immediate intercostal tube drainage is recommended for large secondary pneumothorax (>2 cm), especially in patients over 50, due to high risk of aspiration failure 4, 6
Active intervention is required for breathless patients regardless of pneumothorax size; breathless patients should never be left without intervention 2, 3

If tension pneumothorax is suspected, immediately insert a cannula of adequate length into the second intercostal space in the mid-clavicular line, and leave it in place until a functioning intercostal tube can be positioned 7
Early and aggressive treatment is recommended for pneumothoraces in cystic fibrosis patients, with surgical intervention considered after the first episode if the patient is fit for the procedure 7
Partial pleurectomy has a 95% success rate with little reduction in pulmonary function in cystic fibrosis patients 7

A bubbling chest tube should never be clamped 6
Non-bubbling chest tubes should generally not be clamped 6
If a chest tube is clamped, it should be under specialist supervision in a dedicated ward 6
Patients should be cautioned against flying until follow-up chest radiograph confirms complete resolution 7

Intercostal tube drainage can cause serious complications including organ penetration 6
Complications are more common when sharp metal trocars are used during the procedure 6