Spontaneous Pneumothorax Management (BTS 2023)

Algorithm Steps

1. ▶

   Start

   Spontaneous Pneumothorax Suspected

   Acute onset chest pain, dyspnea; CXR confirms pneumothorax

   1. ◆

      Decision

      Tension Pneumothorax?

      Clinical emergency - treat before imaging

      • Severe respiratory distress
      • Tracheal deviation
      • Hypotension, tachycardia
      • Absent breath sounds
      • Distended neck veins
      1. ⚠

         Warning

         ⚠️ Immediate Decompression

         Do not wait for CXR

         • Needle decompression: 2nd ICS MCL or 4th/5th ICS MAL
         • Large bore cannula (14G)
         • Follow with chest drain insertion
         • High-flow oxygen
         1. ●

            Action

            Chest Drain Insertion

            For SSP or failed aspiration

            • Small bore (10-14Fr) preferred
            • Safe triangle: 4th-5th ICS, anterior to MAL
            • Ultrasound guidance recommended
            • Connect to underwater seal
            • Consider suction if persistent air leak
            1. ◆

               Decision

               Resolution at 48h?

               Assess for lung expansion and air leak

               • Resolved: No air leak, lung expanded
               • Persistent: Ongoing bubbling, incomplete expansion
               1. ●

                  Action

                  Remove Drain & Discharge

                  Air leak resolved, lung expanded

                  • Clamp for 4h, repeat CXR
                  • If stable, remove drain
                  • Discharge with safety-net
                  • Follow-up in 2-4 weeks
                  • Discuss recurrence risk
               2. ✓

                  Outcome

                  Surgical Referral (VATS)

                  For persistent or recurrent pneumothorax

                  • Persistent air leak >5-7 days
                  • Second ipsilateral pneumothorax
                  • First contralateral pneumothorax
                  • Bilateral pneumothorax
                  • High-risk occupations (pilots, divers)
      2. ◆

         Decision

         Primary or Secondary?

         Classify pneumothorax type

         • Primary (PSP): No underlying lung disease, typically age <50, minimal smoking
         • Secondary (SSP): Known lung disease (COPD, ILD, CF) OR age >50 with significant smoking history
         1. ◆

            Decision

            Symptom Severity?

            2023 BTS: Symptoms guide management, not just size

            • Significant symptoms: Breathlessness, pain, hypoxia
            • Minimal symptoms: Comfortable at rest, SpO2 normal
            • High-risk features: Bilateral, hemopneumothorax, tension
            1. ●

               Action

               Conservative Management (PSP)

               For asymptomatic/minimally symptomatic PSP

               • Discharge with safety-net advice
               • Avoid air travel until resolved
               • Return if worsening symptoms
               • Repeat CXR in 2-4 weeks
               • Advise smoking cessation
               1. ✓

                  Outcome

                  Discharge (Conservative)

                  With follow-up plan

                  • Written safety-net advice
                  • Return if worsening symptoms
                  • CXR in 2-4 weeks
                  • Smoking cessation advice
                  • Avoid flying until resolved
            2. ●

               Action

               Ambulatory Management

               Small-bore drain with one-way valve

               • Small-bore chest drain (8-14Fr)
               • Ambulatory device (Heimlich valve/flutter valve)
               • Outpatient management if stable
               • Daily review until resolved
               • Avoid suction initially
            3. ●

               Action

               Active Intervention Required

               For symptomatic patients or SSP

               • Options: Needle aspiration OR chest drain
               • Needle aspiration: 16-18G, 2nd ICS MCL
               • Aspirate up to 2.5L, stop if resistance
               • If fails: Chest drain insertion
               1. ●

                  Action

                  Needle Aspiration

                  First-line for PSP with significant symptoms

                  • 16-18G cannula, 2nd ICS MCL
                  • Aspirate with 50mL syringe via 3-way tap
                  • Stop if: >2.5L aspirated or resistance felt
                  • Repeat CXR post-procedure
                  1. ◆

                     Decision

                     Aspiration Successful?

                     Lung re-expanded, symptoms improved

                     • Success: <2cm rim on CXR, symptoms resolved
                     • Failure: Persistent >2cm or ongoing air leak