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Pneumothorax
Tension is a clinical diagnosis — don't wait for the X-ray. Recognise tension and decompress it. For everyone else, the BTS 2023 approach asks how symptomatic the patient is and whether they have high-risk features, rather than relying only on the size. Built for revision, not live patient decisions.
Settle them, and check the basics
tension or not?Red flags — what each should make you think
Tension pneumothorax is a clinical diagnosis: hypotension, hypoxia, absent breath sounds and a shifting mediastinum in someone who is crashing. Decompress first, then image. In a ventilated patient, rising airway pressures and a falling BP are often the first signs.
Tension pneumothorax
- 🗡Needle decompression
- O₂High-flow oxygen
- ⛑Chest drain promptly
- ☎Senior help
Understand the patient
primary vs secondaryClassify it
- Primary spontaneous (PSP) — no known lung disease, often young, tall, smokers
- Secondary spontaneous (SSP) — underlying lung disease (COPD, CF, ILD, TB, PCP), or age over 50 with significant smoking history. Less reserve, more dangerous
- Traumatic / iatrogenic — after injury, lines, biopsies, ventilation
BTS 2023 approach (spontaneous pneumothorax)
- High-risk features — haemodynamic compromise, significant hypoxia, bilateral, underlying lung disease, age 50+ with smoking history, haemopneumothorax → chest drain
- PSP, minimal symptoms, no high-risk features — conservative management can be considered regardless of size, with follow-up
- PSP with symptoms — options: conservative, needle aspiration, or ambulatory device, based on patient priorities
- SSP — usually admit; drain if symptomatic or large; smaller ones may be aspirated or observed with oxygen
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Severe respiratory distress, hypotension, tachycardia, distended neck veins, tracheal deviation away (late), absent breath sounds.
Clinical.
Needle or finger thoracostomy, then chest drain.
COPD/ILD patient with sudden breathlessness; even a small pneumothorax may cause significant hypoxia.
CXR; CT if bullae make it unclear.
Admit, oxygen (controlled if hypercapnic), drain usually; respiratory team; consider surgical referral for persistent air leak.
Air–fluid level on CXR, trauma, falling Hb.
CXR, CT, FBC.
Large-bore drain, resuscitation, cardiothoracic review if large or ongoing bleeding.
Investigate — what to order, when, and what it tells you
test with a question in mindCXR
Lung ultrasound
CT
ABG
How the plan comes together
disposition · handoverhome
PSP managed conservatively or after successful aspiration, minimal symptoms, reliable, follow-up in respiratory clinic.
Advice: return if more breathless; no flying until resolved on X-ray; avoid diving permanently unless definitive surgery; stop smoking.
admit
SSP, drain in situ, high-risk features, or failed aspiration.
Hand over: type, size, intervention, drain status (bubbling/swinging), oxygen need.
Tension? Decompress before imaging. Everyone else: is it primary or secondary, how symptomatic are they, and are there high-risk features? That decides observe, aspirate or drain. Nicely done getting here.
Clerking template
copy or downloadPneumothorax — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 9 knownFrequently asked questions
quick answersWhat are the red flags for pneumothorax?
- Hypotension, distended neck veins, deviated trachea — think tension pneumothorax
- Hypoxia, haemodynamic compromise — think high-risk — drain
- Underlying lung disease, age over 50 smoker — think secondary pneumothorax
- Bilateral — think high-risk
- Haemopneumothorax — think high-risk — drain
- Ventilated or on NIV — think tension risk
What is the initial management of pneumothorax?
- Needle decompression — 4th/5th intercostal space, just anterior to the mid-axillary line (or 2nd ICS mid-clavicular)
- High-flow oxygen — 15 L non-rebreather
- Chest drain promptly — decompression is a bridge, not the treatment
- Senior help — resus team
Always alongside senior support and your local guideline.
What diagnoses must you not miss in pneumothorax?
- Tension pneumothorax — shock + hypoxia
- Secondary pneumothorax — small but dangerous
- Haemopneumothorax — fluid level · trauma
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for pneumothorax?
- CXR — Bullae can look like pneumothorax — CT if unsure.
- Lung ultrasound — Absent lung sliding, lung point — quick at the bedside.
- CT — Complex cases, bullous disease, trauma.
- ABG — Hypoxia or COPD.
Admit or discharge: how is the plan decided for pneumothorax?
- Home — PSP managed conservatively or after successful aspiration, minimal symptoms, reliable, follow-up in respiratory clinic.
- Admit — SSP, drain in situ, high-risk features, or failed aspiration.
Is there a clerking template for pneumothorax?
Yes — there is a free clerking template for pneumothorax on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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