• Standard erect chest x-ray (CXR) in inspiration (displacement of the pleural line and air-fluid level in the costophrenic angle)

• Consider Computed tomography (CT) scan for complex cases (i.e., for those with underlying bullous lung disease, unwell with small complex SSP).

If a Tension pneumothorax is suspected (cyanosis, sweating, severe tachypnoea, tachycardia, and hypotension) DO NOT wait for a CXR. Immediate treatment is needle decompression (2nd intercostal space in the midclavicular line or safety triangle) followed by definitive treatment with the placement of an intercostal chest drain.

• As per the BTS guidelines attached with emphasis on:

  • Conservative management even with large primary spontaneous pneumothorax (PSP) if minimal symptoms (not short of breath and stable vital observation) with written instructions to return if increasingly breathless

  • Early discussion (prior to intervention if unsure) with the Respiratory team on extension 133722 - Frimley Park Hospital every day between 0900-1700. For Wexham Park Hospital can contact respiratory SpR’s weekdays via bleep/switchboard or MADU consultant daily between 09:00 – 17:00 on 07771336552.

  • Secondary Spontaneous Pneumothorax will require admission and Respiratory review irrespective of an intervention needed or not.

Consider High risk characteristics for intervention as highlighted below in pneumothorax pathway

• In patients with bronchiectasis, antibiotics should be given (see Anti-microbial policy on the intranet for guidance).

• All patients with Cystic Fibrosis and a pneumothorax need to be discussed with a Cystic Fibrosis on Call Consultant urgently contactable via switchboard.

• If admitted with a pneumothorax

  • Refer to the Respiratory team within 24 hours of admission (extension133722) along with EPIC Respiratory Consultation.

• If discharged with a pneumothorax with or without needle aspiration.

  • Clear written advice to be given to the patient to return if worsening breathlessness

  • Refer to the Respiratory team for follow-up within 1 week with a chest X-ray on arrival.

• Smoking cessation

  • Avoid scuba diving

  • Not to fly until review from a doctor to ensure resolution of the pneumothorax

MacDuff, A., Arnold, A., Harvey, J. (2010) ‘Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010’, Thorax, 65, pp. ii18-ii31. Available at: https://thorax.bmj.com/content/65/Suppl_2/ii18.

Roberts ME, Rahman NM, Maskell NA On behalf of the BTS Pleural Guideline Development Group*, et* al British Thoracic Society Guideline for pleural disease Thorax 2023;78:s1-s42.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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