Guideline sources The following summarized guidelines for the evaluation and management of pneumothorax are prepared by our editorial team based on guidelines from the French Society of Thoracic and Cardiovascular Surgery (SFCTCV/SFMU/SFAR/SRLF/SPLF 2023), the British Thoracic Society (BTS 2017; 2011; 2010), and the Society of Critical Care Medicine (SCCM 2015). 1 2 3 4 5 6 Guidelines 1. Classification and risk stratification Classification: As per SPLF 2023 guidelines: https://web.pathway.md/diseases/recUNQd1z7ARkK7mu 1/9 6/29/23, 11:16 PM Pneumothorax Pathway Consider classifying primary spontaneous pneumothorax as large in the presence of a visible rim along the entire axillary line, 2 cm between the lung margin and the chest wall at the hilum level. C Classify pneumothorax as tension pneumothorax when it results in respiratory distress or hemodynamic failure. B As per BTS 2010 guidelines, differentiate large pneumothorax from small pneumothorax based on the presence of a visible rim of > 2 cm between the lung margin and the chest wall (at the level of the hilum), easily measured with the PACS, to determine the rate of resolution. B 2. Diagnostic investigations Clinical evaluation: recognize that symptoms in primary spontaneous pneumothorax may be minimal or absent, while symptoms are greater in secondary spontaneous pneumothorax even if the pneumothorax is relatively small in size. B Show 3 more Diagnostic imaging, X-ray: As per SFCTCV/SFAR/SRLF/SFMU/SPLF 2023 guidelines, consider obtaining a frontal CXR acquired in inspiration, without expiratory films, in patients with suspected primary spontaneous pneumothorax to diagnose pneumothorax and assess its size. E As per BTS 2010 guidelines: Obtain a standard erect CXR in inspiration for the initial diagnosis of pneumothorax. A Insufficient evidence to recommend the widespread adoption of digital imaging (PACS), as it requires diagnostic caution and the presence of a small pneumothorax may not be immediately apparent. I Diagnostic imaging, computed tomography: As per SFCTCV/SFAR/SRLF/SFMU/SPLF 2023 guidelines: Avoid obtaining chest CT as first-line imaging because of its cost, radiation exposure, and accessibility, although it is superior to CXR for the positive diagnosis of primary spontaneous pneumothorax, assessing its size, and ruling out a differential diagnosis. D Obtain low-dose chest CT in case of persistent diagnostic doubt despite obtained investigations. B As per BTS 2010 guidelines, obtain chest CT for uncertain or complex cases B and for the best accurate size calculations. B Diagnostic imaging, ultrasound: As per SFCTCV/SFAR/SRLF/SFMU/SPLF 2023 guidelines, avoid establishing the diagnosis of primary spontaneous pneumothorax solely based on chest ultrasound in the absence of signs of severity. D Show 3 more As per SCCM 2015 guidelines, obtain a chest ultrasound to complement or replace conventional CXR for diagnosing pneumothorax, depending on the clinical setting and the need for rapid results. A https://web.pathway.md/diseases/recUNQd1z7ARkK7mu 2/9 6/29/23, 11:16 PM Pneumothorax Pathway 3. Respiratory support Supplemental oxygen: As per SPLF 2023 guidelines, do not administer supplemental oxygen systematically in patients treated for primary spontaneous pneumothorax. D As per BTS 2017 guidelines: Aim at an oxygen saturation of 94-98% in most cases of pneumothorax if the patient is not at risk of hypercapnic respiratory failure. B Administer high-concentration oxygen (15 L/min flow rate via reservoir mask) in patients with pneumothorax under hospital observation without drainage unless the patient is at risk of hypercapnic respiratory failure. B As per BTS 2010 guidelines, administer supplemental oxygen in patients with pneumothorax and breathlessness. B 4. Medical management Setting of care: As per SPLF 2023 guidelines: Offer outpatient management in patients with large primary spontaneous pneumothorax without signs of immediate severity. B Offer outpatient management with needle aspiration or placement of a mini-chest tube and a one-way valve if the following conditions are present: patient stability after removal of the intrapleural air organized dedicated outpatient care system scheduled consultation with chest ultrasound or CXR at 24-72 hours to follow the evolution. B As per BTS 2010 guidelines: Admit all patients with secondary spontaneous pneumothorax to the hospital for at least 24 hours. B Consider managing patients with secondary spontaneous pneumothorax in an outpatient setting with a Heimlich valve. C Observation: As per SPLF 2023 guidelines: Offer conservative management (monitoring) in patients with small primary spontaneous pneumothorax and without signs of poor tolerance. B Offer outpatient conservative management in patients with small primary spontaneous pneumothorax if the following conditions are present: clinically and radiologically stability after 4 hours organized dedicated outpatient care system scheduled consultation with chest ultrasound or CXR at 24-72 hours to follow the evolution. B https://web.pathway.md/diseases/recUNQd1z7ARkK7mu 3/9 6/29/23, 11:16 PM Pneumothorax Pathway As per BTS 2010 guidelines, offer observation as the treatment of choice in patients with small primary spontaneous pneumothorax without significant breathlessness. B Show 2 more Pain management: Offer pain management based on multimodal analgesia in patients with medically treated (needle aspiration, drainage, or conservative management) primary spontaneous pneumothorax. B Consider administering NSAIDs for a few days after pneumothorax surgery in patients with insufficient locoregional analgesia and non-morphine systemic analgesics to reduce or prevent the use of morphine, recognizing that NSAIDs do not decrease the efficacy of surgical pleurodesis. C Management of tension pneumothorax: As per SPLF 2023 guidelines, perform emergency chest decompression through an anterior (mid-clavicular line at the 2nd intercostal space) or axillary (mid-axillary line at the 4th intercostal space) approach in patients with confirmed tension primary spontaneous pneumothorax. Use dedicated equipment (thoracentesis kit) or any other needle aspiration device as available. B As per BTS 2010 guidelines, ensure heightened awareness for tension pneumothorax in a specific range of clinical situations because tension pneumothorax is a medical emergency. B Show 2 more 5. Nonpharmacologic interventions Smoking cessation: As per SPLF 2023 guidelines, offer smoking (and any other smoked substances) cessation support in patients to minimize the risk of primary spontaneous pneumothorax recurrence. A As per BTS 2010 guidelines, advise smoking cessation to minimize the risk of recurrence. B Physical activity restrictions: avoid advising strict bed rest in patients with primary spontaneous pneumothorax. D Show 2 more 6. Therapeutic procedures Needle aspiration: As per SPLF 2023 guidelines: Perform needle aspiration as a first-line option to remove air from the pleural space in patients with large primary spontaneous pneumothorax without signs of immediate severity. B Consider obtaining ultrasound visualization before needle aspiration using the anterior or axillary approach to reduce the risk of complications. C As per BTS 2010 guidelines: https://web.pathway.md/diseases/recUNQd1z7ARkK7mu 4/9 6/29/23, 11:16 PM Pneumothorax Pathway Recognize that needle (14-16 G) aspiration is as effective as large-bore (> 20 F) chest drains and may be associated with reduced hospitalization and length of stay. A Do not perform repeated needle aspiration unless there are technical difficulties. D Chest tube drainage, indications: As per SFCTCV/SFAR/SRLF/SFMU/SPLF 2023 guidelines: Perform chest tube drainage as a first-line option to remove air from the pleural space in patients with large primary spontaneous pneumothorax without signs of immediate severity. B Consider performing emergency chest tube drainage in patients with any of the following: simultaneous bilateral primary spontaneous pneumothorax with signs of severity or large primary spontaneous pneumothorax hemopneumothorax with signs of severity or large hemopneumothorax primary spontaneous pneumothorax with confirmed pleural adhesion and signs of severity or large primary spontaneous pneumothorax. E As per BTS 2010 guidelines, perform active intervention in patients with primary spontaneous pneumothorax/secondary spontaneous pneumothorax of any size and significant breathlessness. A As per BTS 2010 guidelines, perform placement of a small chest drain as first-line treatment in patients with pneumothorax. B Chest tube drainage, technical considerations: As per SFCTCV/SFAR/SRLF/SFMU/SPLF 2023 guidelines, consider inserting a small-bore chest tube ( 14 Fr) for chest drainage of primary spontaneous pneumothorax. C Show 5 more As per BTS 2010 guidelines, insert a small-bore (< 14 Fr) chest drain in most patients with pneumothorax. B Show 5 more Chest tube drainage (periprocedural analgesia): administer local anesthesia to the chest wall before removing air from the pleural space, either through needle aspiration or chest tube drainage. B Show 2 more Chest tube drainage (considerations for transportation): Recognize that transporting a patient with drained primary spontaneous pneumothorax carries some risks and might be a source of complications. Do not clamp a bubbling tube. Do not clamp a tube in case of positive pressure ventilation due to the risk of overpressure. Consider arranging the transportation of patients with drained spontaneous pneumothorax as follows to reduce the risk of tension pneumothorax: without bubbling: with a chest tube attached to a one-way valve with bubbling: by continuing continuous suction with the fitting of a stand-alone suction pump connected to the 3-compartment drainage system. E Medical pleurodesis: consider performing medical pleurodesis in inoperable patients with secondary spontaneous pneumothorax. C Show 3 more https://web.pathway.md/diseases/recUNQd1z7ARkK7mu 5/9 6/29/23, 11:16 PM Pneumothorax Pathway 7. Perioperative care Perioperative locoregional analgesia: consider administering perioperative locoregional analgesia to reduce postoperative pain in patients undergoing pneumothorax surgery. Consider preferring peripheral locoregional analgesia (paravertebral block, serratus plane block, or intercostal block) over thoracic epidural analgesia. C 8. Surgical interventions Surgical pleurodesis: perform pleurodesis after a second episode of primary spontaneous pneumothorax (ipsilateral or contralateral) regardless of the management method used for the first episode. B Show 4 more Pleurectomy: As per SPLF 2023 guidelines, do not perform surgery as first-line treatment in patients with large primary spontaneous pneumothorax without signs of immediate severity, except in specific situations. D As per BTS 2010 guidelines, seek an early (3-5 days) thoracic surgical opinion for patients with persistent air leaks or failure of the lung to re-expand. B Show 2 more 9. Specific circumstances Pregnant patients: ensure close cooperation between chest physicians, obstetricians and thoracic surgeons as pneumothorax recurrence is more common in pregnancy and poses risks to the mother and fetus. B Show 2 more Patients with hemopneumothorax: consider contacting an expert center (center with a thoracic surgery department) for patients with hemopneumothorax (regardless of its size) as soon as possible to discuss the treatment approach and possibly transfer patients to this center. E Show 2 more Patients with catamenial pneumothorax: Recognize that catamenial pneumothorax is underdiagnosed in female patients with pneumothorax. B Ensure cooperation between thoracic surgeons and gynecologists for a combination of surgical intervention and hormonal therapy. B Patients with pleural adhesions: Consider contacting an expert center (center with a thoracic surgery department) for patients with primary spontaneous pneumothorax (regardless of its size) with confirmed pleural adhesion as soon as possible to discuss the treatment approach and possibly transfer patients to this center. E https://web.pathway.md/diseases/recUNQd1z7ARkK7mu 6/9 6/29/23, 11:16 PM Pneumothorax Pathway Consider performing emergency chest tube drainage in patients with primary spontaneous pneumothorax with confirmed pleural adhesion and signs of severity or large primary spontaneous pneumothorax. E Patients with cystic fibrosis: Initiate early and aggressive treatment with early surgical referral in patients with cystic fibrosis developing pneumothorax. B Recognize that pleural procedures (including pleurodesis) do not have a significant adverse effect on the outcome of subsequent lung transplantation. B Patients with HIV: perform an early intercostal tube drainage and surgical referral in addition to appropriate treatment for human immunodeficiency virus and Pneumocystis jiroveci pneumonia in patients with pneumothorax and human immunodeficiency virus infection. B 10. Patient education Counseling on air travel: As per SPLF 2023 guidelines: Advise waiting at least 2 weeks after primary spontaneous pneumothorax resolution before air travel. E Consider obtaining chest CT and pulmonary function tests before resuming sport skydiving. E As per BTS 2011 guidelines, advise patients with a closed pneumothorax not to travel on commercial flights (with the exception of the very rare case of a loculated or chronic localized air collection which has been very carefully evaluated). B Show 5 more As per BTS 2010 guidelines, advise patients to avoid air travel until full resolution of the pneumothorax. B Counseling on diving: As per SPLF 2023 guidelines, advise refraining from scuba diving in patients with a history of primary spontaneous pneumothorax, even after pleurodesis, due to the risk of fatal barotrauma. E As per BTS 2010 guidelines, advise refraining from diving permanently unless bilateral surgical pleurectomy has been performed and normal postoperative lung function and chest CT has been documented. B Counseling on playing wind instruments: avoid limiting the practice of wind instruments after an episode of primary spontaneous pneumothorax. D 11. Follow-up and surveillance Indications for specialist referral: As per SPLF 2023 guidelines, consider contacting an expert center (center with a thoracic surgery department) for patients with any of the following as soon as possible to discuss the treatment approach and possibly transfer patients to this center: https://web.pathway.md/diseases/recUNQd1z7ARkK7mu 7/9 6/29/23, 11:16 PM Pneumothorax Pathway hemopneumothorax simultaneous bilateral primary spontaneous pneumothorax primary spontaneous pneumothorax with confirmed pleural adhesion. E As per BTS 2010 guidelines, ensure early referral of all patients with secondary spontaneous pneumothorax to a chest physician. Discuss cases of persistent air leak with a thoracic surgeon at 48 hours. B Show 2 more Follow-up: As per SPLF 2023 guidelines: Consider obtaining consultation with a pulmonologist after each episode of primary spontaneous pneumothorax to detect any underlying lung disease. E Avoid obtaining chest CT systematically after primary spontaneous pneumothorax, except in patients with bilateral or recurrent primary spontaneous pneumothorax or in a context suggestive of an underlying disease (secondary spontaneous pneumothorax). D As per BTS 2010 guidelines: Instruct patients to return to the hospital if increasing breathlessness develops. B Obtain follow-up by respiratory physicians in all patients until full resolution. B Clinical findings Symptoms Past medical history Chest pain Asthma Epigastric abdominal pain COPD Shortness of breath Cystic fibrosis Sweating Endometriosis Lung cancer Social history Pneumocystis jiroveci pneumonia Cigarette smoking Tuberculosis Respiratory exam Vital signs breath sounds Hypotension Tachypnea Imaging findings Integument exam Absence of lung sliding Atelectasis Cyanosis Halo sign Lung point sign Signs of pneumothorax Subcutaneous emphysema Studies https://web.pathway.md/diseases/recUNQd1z7ARkK7mu 8/9 6/29/23, 11:16 PM Pneumothorax Pathway 2020 Primary Spontaneous Pneumothorax In patients 14 to 50 years of age with a first-known, unilateral, moderate-to-large primary spontaneous pneumothorax, conservative management was noninferior to interventional management with respect to the rate of lung reexpansion within 8 weeks. Simon G A Brown et al. N Engl J Med. 2020 Jan 30. References 1. St phane Jouneau, Jean-Damien Ricard, Agathe Seguin-Givelet et al. 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Nathan T Mowery, Oliver L Gunter, Bryan R Collier et al. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma. 2011 Feb;70 2 510 8. Open 10. Jochen Hinkelbein, Janusz Andres, Bernd W B ttiger et al. Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery. Eur J Anaesthesiol. 2023 May 23. Online ahead of print. Open https://web.pathway.md/diseases/recUNQd1z7ARkK7mu 9/9