In contrast, tension pneumothorax is a medical emergency and may be treated before imaging – especially if there is severe hypoxia, very low blood pressure, or an impaired level of consciousness. In tension pneumothorax, X-rays are sometimes required if there is doubt about the anatomical location of the pneumothorax. Chest X-ray
A plain chest radiograph, ideally with the X-ray beams being projected from the back (posteroanterior, or "PA"), and during maximal inspiration (holding ones breath), is the most appropriate first investigation. It is not believed that routinely taking images during expiration would confer any benefit. Still, they may be useful in the detection of a pneumothorax when clinical suspicion is high but yet an inspiratory radiograph appears normal. Also, if the PA X-ray does not show a pneumothorax but there is a strong suspicion of one, lateral X-rays (with beams projecting from the side) may be performed, but this is not routine practice. It is not unusual for the mediastinum (the structure between the lungs that contains the heart, great blood vessels, and large airways) to be shifted away from the affected lung due to the pressure differences. This is not equivalent to a tension pneumothorax, which is determined mainly by the constellation of symptoms, hypoxia, and shock.The size of the pneumothorax (i.e. the volume of air in the pleural space) can be determined with a reasonable degree of accuracy by measuring the distance between the chest wall and the lung. This is relevant to treatment, as smaller pneumothoraces may be managed differently.
VATS may also be used to achieve chemical pleurodesis; this involves insufflation of talc, which activates an inflammatory reaction that causes the lung to adhere to the chest wall.If a chest tube is already in place, various agents may be instilled through the tube to achieve chemical pleurodesis, such as talc, tetracycline, minocycline or doxycycline. Results of chemical pleurodesis tend to be worse than when using surgical approaches, but talc pleurodesis has been found to have few negative long-term consequences in younger people. Aftercare
If pneumothorax occurs in a smoker, this is considered an opportunity to emphasize the markedly increased risk of recurrence in those who continue to smoke, and the many benefits of smoking cessation. It may be advisable for someone to remain off work for up to a week after a spontaneous pneumothorax. If the person normally performs heavy manual labor, several weeks may be required. Those who have undergone pleurodesis may need two to three weeks off work to recover.Air travel is discouraged for up to seven days after complete resolution of a pneumothorax if recurrence does not occur. Underwater diving is considered unsafe after an episode of pneumothorax unless a preventive procedure has been performed. Professional guidelines suggest that pleurectomy be performed on both lungs and that lung function tests and CT scan normalize before diving is resumed. Aircraft pilots may also require assessment for surgery. Neonatal period
For newborn infants with pneumothorax, different management strategies have been suggested including careful observation, thoracentesis (needle aspiration), or insertion of a chest tube.