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Pneumothorax

Key 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).
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Guidelines

1.Classification and risk stratification

Classification
As per SPLF 2023 guidelines:
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
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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
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  • Diagnostic imaging (X-ray)

  • Diagnostic imaging (CT)

  • Diagnostic imaging (ultrasound)

3.Respiratory support

Supplemental oxygen: as per SPLF 2023 guidelines, do not administer supplemental oxygen systematically in patients treated for primary spontaneous pneumothorax.
D

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

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  • Observation

  • Pain management

  • Management of tension pneumothorax

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

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  • Physical activity restrictions

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

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  • Chest tube drainage (indications)

  • Chest tube drainage (technical considerations)

  • Chest tube drainage (periprocedural analgesia)

  • Chest tube drainage (considerations for transportation)

  • Medical pleurodesis

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
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  • Pleurectomy

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
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  • Patients with hemopneumothorax

  • Patients with catamenial pneumothorax

  • Patients with pleural adhesions

  • Patients with cystic fibrosis

  • Patients with HIV

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

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  • Counseling on diving

  • Counseling on playing wind instruments

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:
hemopneumothorax
simultaneous bilateral primary spontaneous pneumothorax
primary spontaneous pneumothorax with confirmed pleural adhesion.
E

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  • Follow-up