Pneumothorax — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Tension pneumothorax?
   Is this a tension pneumothorax? (Tension pneumothorax (a clinical emergency): respiratory distress + hypotension, tracheal deviation, JVD, absent breath sounds and hyper-resonance on the affected side. It is a clinical diagnosis — do not wait for imaging.)
   • Tension pneumothorax → Tension → immediate decompression
   • Non-tension (spontaneous) → Spontaneous · type & high-risk
2. [End] Tension → immediate decompression
   Immediate needle decompression (large-bore cannula, 2nd intercostal space mid-clavicular line, or 4th/5th intercostal space anterior axillary line), do not wait for a chest X-ray; then place a chest drain. Minimize airway pressure in ventilated patients.
3. [Decision] Spontaneous · type & high-risk
   Primary or secondary? Any high-risk features? (High-risk features: hemodynamic instability, marked hypoxemia, bilateral, underlying lung disease (secondary SSP), hemopneumothorax, age ≥50 with a heavy smoking history. BTS 2023 is symptom-directed rather than purely size-based.)
   • Primary (PSP), mild symptoms → Primary, mild symptoms
   • Secondary (SSP) or high-risk features → Secondary or high-risk
4. [End] Primary, mild symptoms
   Primary spontaneous pneumothorax (PSP), no/minimal symptoms (no significant pain or breathlessness, no physiological disturbance) — can be managed conservatively regardless of size (observation, outpatient follow-up); ambulatory management at capable centers. For significant symptoms not suitable for conservative care, choose needle aspiration, an ambulatory device or a chest drain by priority goals. Stop smoking to prevent recurrence.
5. [End] Secondary or high-risk
   Secondary spontaneous pneumothorax (SSP, underlying lung disease) or high-risk features: usually need intervention — place a chest drain (some small-volume/minimally symptomatic cases can be admitted for observation); needle aspiration is an option; admit with oxygen to aid resorption and treat the underlying disease. Persistent air leak/recurrence → thoracic surgery (VATS).

Source guidelines & references

• BTS 2023 Pleural disease guideline (spontaneous pneumothorax). Thorax 2023
• ERS/EACTS/ESTS 2024 Clinical practice guideline on adult spontaneous pneumothorax

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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