What is the current recommended management approach for pneumothorax in adult patients, including assessment of clinical stability, size, underlying lung disease, and tension physiology?

Management of Pneumothorax: Recent Guidelines

Initial Assessment and Immediate Management

Conservative management without chest tube placement is now the preferred approach for minimally symptomatic or asymptomatic primary spontaneous pneumothorax in clinically stable adults, regardless of pneumothorax size. 1

Clinical Stability Criteria

Before deciding on management, assess for clinical stability defined as: 2

• Respiratory rate <24 breaths/min
• Heart rate 60-120 beats/min
• Normal blood pressure
• Room air oxygen saturation >90%
• Ability to speak in whole sentences between breaths

Tension Pneumothorax Recognition

Immediate needle decompression followed by tube thoracostomy is mandatory for tension pneumothorax with hemodynamic compromise. 2 This is a life-threatening emergency that cannot wait for imaging confirmation. 3

Management Algorithm Based on Stability and Type

Primary Spontaneous Pneumothorax (No Underlying Lung Disease)

For clinically stable patients with minimal or no symptoms:

• Conservative observation is recommended regardless of pneumothorax size 1
• Observe in emergency department for 3-6 hours with repeat chest radiograph 2
• Discharge home if no progression on repeat imaging 2
• High-flow oxygen (10 L/min) increases reabsorption rate 2

For clinically stable patients with large pneumothorax (≥2-3 cm) who are symptomatic:

• Ambulatory management with small-bore catheter (≤14F) or 16-22F chest tube should be considered 1, 2
• Hospitalization is generally indicated 2

For clinically unstable patients:

• Immediate chest tube placement (24-28F) is mandatory regardless of size 2, 4
• Hospitalization required 2

Secondary Spontaneous Pneumothorax (With Underlying Lung Disease)

Even small secondary pneumothoraces require more aggressive management due to higher mortality risk: 2

• Hospitalization recommended even for small pneumothoraces (<1 cm depth) 2
• Observation alone appropriate only for asymptomatic patients with very small (<1 cm) or isolated apical pneumothoraces 2
• Large secondary pneumothoraces require chest tube placement (24-28F if mechanically ventilated) 2, 4

Chest Tube Selection and Management

Tube Size Selection

The 2023 British Thoracic Society guideline supports smaller tubes than historically used: 1

• Unstable patients or mechanical ventilation: 24-28F tubes 2, 4
• Stable patients with large pneumothorax: 16-22F tubes 2, 4
• Small pneumothoraces in stable patients: Small-bore catheters (≤14F) acceptable 2, 4
• Tubes >28F are generally unnecessary 4

Drainage System Configuration

• Connect to water-seal device with or without suction 2, 4
• Apply suction at -20 cm H₂O when lung re-expansion is incomplete 4
• Heimlich valves may be used in selected cases 2, 4

Tube Removal Criteria

Remove chest tube when all of the following are met: 4

• 24-hour drainage <150 mL
• No air leak present
• Complete radiographic lung re-expansion
• After last documented air leak, clamp tube for ~4 hours and obtain repeat chest radiograph before removal 4

Management of Persistent Air Leak

Observe for up to 4 days to allow spontaneous closure: 4

• If leak persists beyond 4 days, refer for thoracoscopic surgery 4
• Do not place additional chest tubes 4
• Chemical pleurodesis via chest tube is generally not recommended unless surgery is contraindicated 4
• For non-surgical candidates, autologous blood pleurodesis or endobronchial therapies should be considered 1

Recurrence Prevention

Indications for Surgical Intervention

The 2023 BTS guideline provides clear recommendations for elective surgery: 1

Primary pneumothorax:

• Elective surgery may be considered after first episode for at-risk professionals (divers, airline pilots, military personnel) or those who developed tension pneumothorax 1
• Elective surgery should be considered for second ipsilateral or first contralateral pneumothorax 1

Secondary pneumothorax:

• Consider intervention after first occurrence due to higher mortality risk 2
• Chemical pleurodesis can be considered for prevention of recurrent secondary pneumothorax in adults with severe COPD who significantly decompensated 1

Surgical Approach

Video-assisted thoracoscopy (VATS) is the preferred surgical approach: 1, 4

• Surgical success rates: 95-100% for thoracoscopy vs 78-91% for chemical pleurodesis 4
• Thoracotomy access should be considered for lowest recurrence risk in high-risk occupations 1
• Surgical pleurodesis and/or bullectomy should be considered 1
• Bullectomy with stapler is the preferred operative technique 4

Critical Pitfalls to Avoid

Never insert chest tube using a trocar - this significantly increases risk of iatrogenic hemothorax, pulmonary laceration, and organ injury 4

Never clamp a bubbling chest tube - this can convert a simple pneumothorax into tension pneumothorax 4

Do not reflexively place chest tubes for small pneumothoraces in stable patients - observation is safer and avoids unnecessary pain and complications 2, 4

Breathless patients should not be left without intervention regardless of pneumothorax size on chest radiograph - small pneumothoraces can rapidly progress to tension physiology when positive pressure ventilation is initiated 2, 5

Post-Discharge Counseling

All patients discharged after pneumothorax must receive: 1

• Verbal and written advice to return immediately if breathlessness develops
• Discharge and activity advice
• Follow-up with respiratory physician to ensure resolution and explain recurrence risk

Key Changes from Previous Guidelines

The 2023 British Thoracic Society guideline represents a significant shift toward more conservative management, particularly the recommendation that conservative management can be considered for minimally symptomatic primary spontaneous pneumothorax regardless of size 1. This contrasts with older approaches that used rigid size cutoffs (2-3 cm) to determine intervention. The emphasis is now on clinical stability and symptom burden rather than pneumothorax size alone. 1, 6