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Internal Medicine›Condition·Updated Apr 17, 2026·v1

Pneumothorax

Pneumothorax is a common pleural disorder ranging from simple spontaneous air leaks to life-threatening tension physiology. Diagnosis is primarily radiographic, though ultrasound is superior in emergencies. Management prioritizes stability, with a trend toward conservative care for small leaks and surgical intervention for persistent or recurrent cases.

High Evidence174 references·6,044 words·25 min read·v1
pulmonologyemergency_medicinethoracic_surgerycritical_care

Quick Reference

RxDrug of choiceSupplemental Oxygen (increases absorption rate)
AltAlternativesSimple aspiration (16-18G cannula)
⊘AvoidAir travel (until 1-2 weeks post-resolution), Scuba diving (permanently unless pleurectomy performed)
DxTest of choiceUpright PA Chest X-ray (Standard); POCUS (Emergency/Trauma)
ScKey scoreBTS Criteria (Large = ≥2cm at hilum)
→When to referPersistent air leak >5 days, recurrent episodes, bilateral collapse, high-risk professions
Pneumothorax management is driven by clinical stability and size; tension pneumothorax requires immediate clinical diagnosis and needle decompression.
Pneumothorax is the accumulation of air within the [[pleural space]], leading to partial or complete lung collapse. It is broadly categorized into spontaneous (primary or secondary), traumatic, and iatrogenic types. Primary spontaneous pneumothorax (PSP) typically affects young, healthy individuals without known lung disease, while secondary spontaneous pneumothorax (SSP) occurs in the context of underlying pathology such as [[COPD]], [[cystic fibrosis]], or [[Birt-Hogg-Dubé syndrome]]. The most critical clinical variant is [[tension pneumothorax]], a life-threatening emergency where a one-way valve mechanism causes intrapleural pressure to exceed atmospheric pressure, resulting in obstructive shock. Management ranges from conservative observation and supplemental oxygen to needle decompression, tube [[thoracostomy]], and surgical pleurodesis, depending on the size of the collapse and the patient's hemodynamic stability.

Overview and Recommendations

Background

  • •Define pneumothorax as the presence of air between the visceral and parietal pleura, which disrupts the negative pressure required for lung expansion and can lead to cardiovascular impairment.
  • •Distinguish between primary spontaneous pneumothorax (PSP), occurring in patients without overt lung disease (often tall, thin male smokers), and secondary spontaneous pneumothorax (SSP), which complicates existing conditions like , , or .
  • •Recognize the genetic risk associated with (BHDS), an autosomal dominant condition caused by FLCN gene mutations that leads to pulmonary cysts and a nearly 60% lifetime risk of spontaneous pneumothorax.
  • •Identify iatrogenic triggers, including CT-guided lung biopsies (up to 43% risk for small nodules), central line placement, and mechanical ventilation, which can cause barotrauma and rapid progression to tension physiology.
  • •Understand the 'buffalo chest' phenomenon, an iatrogenic or congenital communication between the two pleural cavities (often seen after repair) that allows a unilateral air leak to become a life-threatening bilateral pneumothorax.
  • •Differentiate simple pneumothorax from , where increasing intrapleural pressure shifts the mediastinum and compresses the vena cava, leading to decreased venous return and obstructive shock.

Evaluation

  • •Suspect pneumothorax in any patient presenting with sudden-onset pleuritic chest pain and dyspnea, particularly if symptoms began at rest or following a thoracic procedure.
  • •Examine the patient for classic physical findings, including diminished or absent breath sounds on the affected side, hyper-resonance (tympany) on percussion, and decreased tactile fremitus.
  • •Monitor vital signs closely for 'red flags' of tension physiology: tachycardia, hypotension, SpO2 < 90%, and tracheal deviation away from the affected side.
  • •Obtain an upright posteroanterior (PA) chest X-ray as the first-line diagnostic study to identify the visceral pleural line and the absence of peripheral lung markings.
  • •Utilize point-of-care ultrasound (POCUS) in emergency or trauma settings to look for the 'lung point' sign (100% specific for pneumothorax) and the absence of 'lung sliding' or 'B-lines'.
  • •Measure the size of the pneumothorax using the British Thoracic Society (BTS) criteria (large = ≥2 cm rim of air at the level of the hilum) or the American College of Chest Physicians (ACCP) criteria (large = ≥3 cm at the apex).
  • •Identify the 'deep sulcus sign' on supine chest radiographs in trauma patients, characterized by an abnormally deep and radiolucent costophrenic angle.
  • •Rule out mimics such as giant pulmonary bullae, which typically have a concave inner border, and diaphragmatic hernia, which may show bowel loops in the thoracic cavity (pseudotension pneumothorax).
  • •Consider specialized imaging like MRI for suspected catamenial pneumothorax (related to ) if symptoms recur in sync with the menstrual cycle.
  • •Screen for underlying systemic diseases in patients with recurrent or bilateral episodes, including (LAM) in females or BHDS in those with a family history of renal tumors.

Management

  • •Administer supplemental oxygen (high-flow) to all patients requiring intervention, as this increases the rate of pleural air absorption by fourfold by reducing the partial pressure of nitrogen.
  • •Manage stable patients with a small PSP (<2 cm) conservatively with observation and a repeat chest X-ray in 6–24 hours; discharge is appropriate if the pneumothorax is stable and follow-up is guaranteed.
  • •Perform simple aspiration using a 16–18G cannula for large PSPs in stable patients; this is often better tolerated than chest tube insertion and may avoid hospitalization.
  • •Insert a small-bore chest tube (10–14 Fr) for patients with SSP, failed aspiration, or those who are symptomatic and unstable.
  • •Perform immediate needle decompression for suspected using a 14G needle in the 2nd intercostal space (midclavicular line) or the 4th/5th intercostal space (anterior axillary line) before waiting for imaging.
  • •Apply low-pressure negative suction (-20 cmH2O) if the lung fails to re-expand after 24–48 hours of water seal drainage or if a large air leak is present.
  • •Monitor for re-expansion pulmonary edema (RPE) when draining a lung that has been collapsed for >72 hours; avoid high-volume suction initially in these chronic cases.
  • •Consult thoracic surgery for a persistent air leak (PAL) lasting more than 5–7 days, or for recurrent, bilateral, or high-risk occupational (e.g., divers, pilots) pneumothoraces.
  • •Consider an autologous blood patch (50–100 mL of the patient's blood instilled via chest tube) or endobronchial valves for patients with PAL who are not candidates for surgery.
  • •Implement Respiratory Training-Based Rehabilitation (RTBR) post-procedure to improve FEV1 and reduce the duration of hospitalization.
  • •Remove the chest tube only after the air leak has ceased (no bubbling in the water seal) and the lung remains fully expanded on a trial of water seal for 4–24 hours.
  • •Advise patients to avoid air travel until at least 1–2 weeks after radiographic resolution has been confirmed, as hypobaric conditions can cause residual air to expand.
  • •Counsel all patients on permanent smoking cessation, as continued tobacco or cannabis use significantly increases the risk of recurrence.
  • •Refer patients with suspected genetic syndromes (e.g., BHDS) for genetic counseling and screening for associated visceral malignancies like renal cell carcinoma.

Board Review — High Yield

  • •Lung point — The most specific ultrasound sign for pneumothorax; represents the physical transition between collapsed and inflated lung.
  • •Deep sulcus sign — An abnormally deep, radiolucent costophrenic angle on a supine CXR, indicating pneumothorax in trauma patients.
  • •Birt-Hogg-Dubé syndrome — FLCN mutation; triad of spontaneous pneumothorax, fibrofolliculomas, and renal cell carcinoma.
  • •Catamenial pneumothorax — Recurrent pneumothorax occurring within 72 hours of menses onset; caused by thoracic endometriosis.
  • •Re-expansion pulmonary edema — A potential complication of rapid re-inflation of a lung that has been collapsed for more than 3 days.
  • •Buffalo chest — A rare condition where the pleural spaces communicate, leading to bilateral collapse from a single-sided air leak.
  • •Spiked helmet sign — An ECG pattern (ST-elevation with dome-and-spike) that can be seen in pneumothorax and mimics MI.
  • •Vaping-associated spontaneous pneumothorax (VASP) — An emerging entity in young patients using electronic cigarettes or cannabis concentrates.

Deep Dive — Evidence Details

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