Level 1 of 6Core
Pneumothorax: recognition, decompression and drainage
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- Suspect it: sudden-onset unilateral pleuritic chest pain and breathlessness, often at rest — the patient can often name the moment. Pain that settles over 24 hours does not mean the pneumothorax has settled.
- The diagnostic combination: absent or diminished breath sounds with a hyper-resonant percussion note. A normal chest examination does not exclude it — below 15% of a hemithorax the only abnormality may be mild tachycardia.
- Look for tension before anything else: rapidly progressive breathlessness with marked tachycardia, hypotension, cyanosis and tracheal displacement away from a silent, hyper-resonant hemithorax. A central trachea does not exclude tension — hypotension and hypoxaemia with a silent hyper-resonant hemithorax is the more reliable evidence.
- Erect PA chest radiograph is the diagnostic test — but never wait for it in suspected tension. Size it: interpleural rim ≥ 2 cm at the hilum (≥ 1 cm in secondary pneumothorax) is the aspiration threshold; > 15% of the hemithorax is large; a 2 cm rim means roughly 50% volume loss. Convex lung edge = pneumothorax, concave = bulla; on a supine film look for the deep sulcus sign.
- Screen for the six high-risk characteristics: haemodynamic compromise, hypoxia, bilateral pneumothorax, underlying lung disease (secondary pneumothorax), age over 50 with a significant smoking history, and haemopneumothorax — any one means a chest drain where it is safe to intervene.
- Get an ECG in every adult and check the other side of the film: pneumothorax mimics myocardial infarction, and a left-sided pneumothorax itself shifts the QRS axis; bilateral pneumothorax is easily missed.
Manage now— do this, in order
- Tension: decompress at the bedside on clinical grounds, before any imaging. A 14-16 gauge cannula (the longest available) into the 2nd intercostal space, mid-clavicular line, on the affected side; in a large or muscular adult the 4th-5th intercostal space in the anterior-to-mid axillary line. Insert immediately above the upper border of the rib below. Children: 18-20 gauge in an infant or small child, 16-18 gauge in an older child.Doctor / Nurse
- Stop or minimise any positive-pressure ventilation — it is generating the tension — and remember the cannula is temporary: a chest drain must follow immediately. In cardiac arrest with suspected tension, decompress during CPR, both sides if the side cannot be determined.
- Oxygen is a treatment, not just support: it accelerates reabsorption of pleural air. Target SpO2 94-98% (88-92% if at risk of type II respiratory failure); in a shocked, peri-arrest or profoundly hypoxaemic patient give a reservoir mask at 15 L/min and correct the target afterwards.
- Analgesia, because pleuritic pain splints the chest: paracetamol 1 g PO/IV 6-hourly, max 4 g/24 h (child 15 mg/kg 4-6-hourly, max 60 mg/kg/24 h); add ibuprofen 400 mg PO 8-hourly with food if not contraindicated. Severe pain or before drain: morphine 2-5 mg IV titrated every 5-10 minutes (halve in frail elderly), with naloxone 400 micrograms IV immediately available.Doctor / Nurse
- Needle aspiration is the first intervention for a symptomatic pneumothorax with no high-risk characteristic (rim ≥ 2 cm, > 15%, or significant dyspnoea): 2% lidocaine to the pleura (max 3 mg/kg), 16-gauge cannula in the 2nd intercostal space mid-clavicular line, three-way tap and 50 mL syringe, aspirate up to 2.5 L; stop if > 2.5 L, resistance, or excessive coughing; repeat the film in expiration. Never aspirate a traumatic or tension pneumothorax, a ventilated, hypoxic or haemodynamically compromised patient, or suspected bulla.Doctor / Nurse
- Insert an intercostal drain when aspiration fails, > 2.5 L was aspirated, the patient was very breathless, after tension decompression, in any secondary pneumothorax, any high-risk characteristic, on mechanical ventilation, or in trauma: triangle of safety (4th intercostal space mid-axillary line), never below the 5th space, blunt dissection and never a trocar, small-bore 7F-14F tube to an underwater seal or Heimlich valve, bottle upright and below the chest.Doctor / NurseNot available at your setup — Chest drain / tube thoracostomy.
- Never clamp an intercostal drain — with a continuing leak it recreates tension. A drain that neither swings nor bubbles with an unexpanded lung is blocked, kinked or displaced — not resolution. Bubbling beyond 48 hours means CT and referral for surgical repair.
- Conservative management is active treatment for the asymptomatic patient irrespective of size: oxygen, analgesia, rest, repeat radiograph every 24 hours. A patient meeting no intervention criterion may be observed for 6 hours and followed up within 10 days. Advise no flying until 7 days after confirmed full re-inflation, no diving unless surgically pleurodesed, and smoking cessation.
Analgesia
| Drug | Adult | Child |
|---|---|---|
| Paracetamol | 1 g PO/IV 6-hourly, max 4 g/24 h | 15 mg/kg 4-6-hourly, max 60 mg/kg/24 h |
| Ibuprofen | 400 mg PO 8-hourly with food | 5-10 mg/kg 6-8-hourly, max 30 mg/kg/24 h |
| Morphine | 2-5 mg IV titrated every 5-10 min | 0.1 mg/kg IV slowly titrated |
| Naloxone (reversal) | 400 micrograms IV | 10 micrograms/kg IV |
| Lidocaine (local) | Max 3 mg/kg (~10 mL of 2% in 70 kg) | Max 3 mg/kg |
Refer / escalate
Decompress on the spot and call for help immediately for suspected tension, bilateral pneumothorax, pneumothorax on mechanical ventilation, or haemodynamic compromise; refer for CT and surgical repair if bubbling continues beyond 48 hours or the lung fails to re-expand, and for surgical pleurodesis after any second or bilateral pneumothorax, failed tube thoracostomy, or a first secondary pneumothorax with low respiratory reserve.
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