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Home | Articles | Respiratory | Spontaneous Pneumothorax

Spontaneous Pneumothorax

Last updated 17th July 2023

The British Thoracic Society have updated their pleural disease guidelines in 2022. The full updated guideline is available here: British Thoracic Society Guidelines on Pleural Disease

The management of pneumothorax has changed significantly with the introduction of this guideline, and is now largely based on symptoms, rather than size.

The below guidance applies to spontaneous pneumothoraxes only. Pneumothorax which is secondary to trauma is managed differently – usually with a surgical chest drain. Low impact falls with rib fractures in the elderly causing pneumothorax should be managed as trauma in the first instance.

Common Terminology

  1. Primary Spontaneous Pneumothorax (PSP) – no underlying lung disease, typically tall thin young male
  2. Secondary Spontaneous Pneumothorax (SSP) – underlying lung disease, esp rupture of bulla
  3. Tension = pneumothorax + cardiorespiratory collapse
  4. Although the above terminology is still commonly used, and has some place in the 2022 guidelines, it may be more useful to consider whether the patient you are seeing has high risk characteristics along with a pneumothorax.

High Risk Characteristics

  1. Haemodynamic compromise (tension pneumothorax)
  2. Significant hypoxia
  3. Bilateral pneumothorax
  4. Underlying lung disease
  5. ≥50 years of age with significant smoking history


  1. Typically sudden onset pleuritic chest pain ± dyspnoea, although may be largely asymptomatic
  2. Patients with an underlying lung disease usually have greater symptoms, even if the pneumothorax is small
  3. Classic signs are hyper-resonance with silence, though quite often examination is unremarkable
  4. Severe symptoms with respiratory distress suggest tension pneumothorax


  1. In young adults will usually be visible on a standard inspiratory film
  2. Small pneumothorax in COPD usually requires treatment but can be difficult to detect
  3. May be missed in supine film as air rises to least dependent areas
  4. Sometimes difficult to distinguish from emphysematous bullae that have not ruptured, esp in cannabis users and severe emphysema
  5. CT scanning recommended for uncertain or complex cases (see algorithm below)


  1. All patients with spontaneous pneumothorax should be referred to respiratory within 24hrs, or on Monday if over a weekend.  Aim for early transfer to B2.


Notes on Management

  1. The 2022 guidelines are very patient centred, and focus on symptoms, not the size of the pneumothorax.  Base your management around your patient’s symptoms and preferences.
  2. A pneumothorax of >2cm is still considered to be the sufficient safe size for intervention. This is a measurement of 2cm size anywhere (rather than 2cm at the hilum as per the 2010 guidance)
  3. Although an ambulatory OP pathway is recommended by BTS, this is much harder to achieve in a rural centre like DGRI. We also do not have a regular supply of ambulatory devices, so this is not something that can be offered on a regular basis. Make sure you have discussed any plans for ambulatory conservative management with either the CAU consultant or the respiratory team to arrange how the patient will be followed up, and who is responsible for this.
  4. Needle aspiration can be attempted with either a wide bore (grey) cannula and a 3 way tap or using a Rocket 8ch aspiration kit in either the second intercostal space, midclavicular line, or within the safe triangle.
  5. If inserting a chest drain this should be a 12ch guidewire chest drain with an underwater seal.
  6. Further treatment options include chest drain suction, chemical pleurodesis and thoracic surgery – if considering any of these the patient should be discussed with the respiratory team (if not already)

Insertion of Chest Drain

Chest drain insertion is a potentially life-threatening procedure, and should not be attempted without supervision, unless you have been signed off as able to perform the procedure without direct supervision.

  1. Size 12 guidewire (seldinger) drain usually adequate but occasionally needs to be changed later for a bigger drain (usually if there is significant surgical emphysema)
  2. Most drains for pneumothorax will be inserted within the “safe triangle” – i.e. 5th rib space in the mid axillary line between the latissimus dorsi and pectoralis major.
  3. Always use a 3-way tap if one is provided in the chest drain kit you are using – this is safe in pneumothorax and makes later flushing of the drain (see below) much easier.
  4. Make sure the underwater seal drain is properly connected
  5. Never lift a chest drain bottle above the patient’s waist.

Chest Drain Management

  1. This is best done on respiratory ward
  2. Lung re-expansion usually causes coughing and some degree of chest discomfort – prescribe analgesia at time of insertion.
  3. Do not employ suction routinely as increases risk of Re-expansion Pulmonary Oedema (RPO)
  4. Never clamp a bubbling drain as this can lead to tension pneumothorax
  5. If still bubbling at 2 days suction can be used with caution (use high-volume low-pressure suction – start at 5 cm water pressure – easier to do this with specialised lid for drain. Do not use wall suction) – refer to Respiratory if this has not been done already
  6. If persistent air leak/failure of re-expansion, seek early (3-5 days) Thoracic Surgical opinion
  7. If drain stops bubbling or the column of fluid stops swinging then this means that the drain has blocked – see management below 

Pathway for Managing a “Not Swinging, Not Bubbling” Chest Drain

All chest drains should “swing”. This is a term that describes oscillation of the water in the drain bucket or tube as the patient breathes. If this is not occurring, the drain is most likely blocked with something. If the drain is “swinging”, but no longer bubbling, the lung may be fully re-expanded. In this situation perform a CXR to check for lung re-expansion.

Steps to unblock a chest drain

  1. Equipment required
    • Dressing pack
    • Sterile gloves
    • Alcohol wipe or chloroprep stick
    • 20ml syringe
    • 0.9% saline – draw up in a sterile way or squeeze into the bowel in the dressing pack with a non-touch technique
  2. Put on sterile gloves
  3. Swab 3 way tap and side port with alcohol wipe or chloroprep
  4. Turn 3 way tap off to patient (picture1)
  5. Remove side port cap and attach syringe with at least 20mls saline.
  6. Turn 3 way tap on to patient (picture 2) and flush into drain.
  7. Turn 3 way tap off to patient again, remove syringe and replace cap.
  8. Turn drain on to patient and bottle (picture 3) – if now swinging +/- bubbling, problem is fixed.
  9. If not swinging it is reasonable to repeat the above steps to see if this helps.
  10. If still not swinging or unable to flush – CXR to check drain position or for resolution of pneumothorax.

How the drain flushes can tell you a lot about what is causing the problem.

  1. If it flushes easily, but still doesn’t swing, the lung may be up and wrapped around the drain – CXR to confirm
  2. If it flushes with a feeling of resistance, then a sudden give, debris was likely blocking the drain. If now swinging/bubbling, allow to drain further before re-xraying.
Picture 1
Picture 2
Picture 3

Removal of Chest Drain

  1. Remove when CXR confirms lung fully inflated and when drain has stopped bubbling for 24 hours
  2. Drain should be removed either in expiration or with the patient holding their breath. (not in inspiration due to risk of entraining air through the hole)
  3. Wound closure suture not normally required for size 12ch drain
  4. If wound closure suture required, use mattress suture

Further Advice

  1. Smokers should be strongly advised to quit as quitting reduces risk of recurrence
  2. Advise not to fly until 7 days after radiological resolution of the pneumothorax
  3. Scuba diving is permanently contraindicated unless the patient undergoes bilateral pleurodesis


Content by Lissy McCully