Supplemental oxygen (non-rebreather mask) initially for all
Needle decompression followed by chest tube insertion
ATLS guidelines recommend 5cm angiocath at 2nd intercostal<unk> ace at the mid-clavicular line
More recent evidence shows higher success rates with 4th/5th intercostal<unk> ace at the anterior or mid-axillary line
Small AND asymptomatic (no dyspnea)
Observe on supplemental oxygen (non-rebreather mask) for 6 hours; repeat CXR and discharge if no progression; return in 24 hours for a recheck
Large OR symptomatic (e.g. dyspnea)
Aspiration (see below)
If fail, admit with chest tube to suction for thoracoscopy (VATS)^
Observe on supplemental oxygen (non-rebreather mask) for 6 hours; repeat CXR and discharge if no progression; return in 24 hours for a recheck
Aspiration (see below)
If fail, admit with chest tube to suction for thoracoscopy (VATS)^
If fail, admit with chest tube to suction for thoracoscopy (VATS)^
British Thoracic Society Protocol
2020 study supports conservative therapy vs chest tube.   however there are issues with study including “significant drop out rate, the relatively large number of protocol violations, the large inferiority margins and the short intervention time.”
Inclusion criteria
14 to 50 years of age
unilateral primary<unk>  of 32% or more on chest radiography according to the Collins method (sum of interpleural distances, >6 cm)
Exclusion criteria 
Secondary pneumothorax, defined as pneumothorax occurring in the setting of acute trauma (including iatrogenic) or underlying lung disease including but not limited to COPD, pulmonary fibrosis, TB, cystic fibrosis, lung cancer and asthma that requires regular preventative medication or has been symptomatic within the last two years
Previous<unk>  on the same side 3. Coexistent haemothorax (i.e.<unk> ontaneous haemopneumothorax)
Bilateral pneumothorax
Clinical instability suggesting tension pneumothorax; respiratory distress persisting despite oxygen and parenteral narcotic analgesia (RR >30/min or<unk> O2 <90%), SBP <90 mmHg, HR greater than or equal to SBP.
Pregnancy at time of enrolment
Social circumstances whereby the patient either does not have adequate support after discharge to re-attend hospital if required, or is unlikely to present for study follow up.
Air travel within the next 12 weeks if this cannot be deferred should the pneumothorax be slow to resolve"
Observed for a minimum of 4 hours then repeat chest X-ray.
Discharge if no supplementary oxygen and walking comfortably,
Chest tubes placed if:
clinically significant symptoms persisted despite adequate analgesia
chest pain or dyspnea prevented mobilization
patient was unwilling to continue with conservative treatment
the patient’s condition became physiologically unstable (systolic blood pressure of <90 mm Hg, heart rate in beats per minute greater than or equal to systolic blood pressure in millimeters of mercury, respiratory rate of >30 breaths per minute, or<unk> o2  of <90% while the patient was breathing ambient air)
repeat chest radiograph showed an enlarging pneumothorax along with physiological instability.
Inclusion criteria
14 to 50 years of age
unilateral primary<unk>  of 32% or more on chest radiography according to the Collins method (sum of interpleural distances, >6 cm)
Exclusion criteria 
Secondary pneumothorax, defined as pneumothorax occurring in the setting of acute trauma (including iatrogenic) or underlying lung disease including but not limited to COPD, pulmonary fibrosis, TB, cystic fibrosis, lung cancer and asthma that requires regular preventative medication or has been symptomatic within the last two years
Previous<unk>  on the same side 3. Coexistent haemothorax (i.e.<unk> ontaneous haemopneumothorax)
Bilateral pneumothorax
Clinical instability suggesting tension pneumothorax; respiratory distress persisting despite oxygen and parenteral narcotic analgesia (RR >30/min or<unk> O2 <90%), SBP <90 mmHg, HR greater than or equal to SBP.
Pregnancy at time of enrolment
Social circumstances whereby the patient either does not have adequate support after discharge to re-attend hospital if required, or is unlikely to present for study follow up.
Air travel within the next 12 weeks if this cannot be deferred should the pneumothorax be slow to resolve"
Observed for a minimum of 4 hours then repeat chest X-ray.
Discharge if no supplementary oxygen and walking comfortably,
Chest tubes placed if:
clinically significant symptoms persisted despite adequate analgesia
chest pain or dyspnea prevented mobilization
patient was unwilling to continue with conservative treatment
the patient’s condition became physiologically unstable (systolic blood pressure of <90 mm Hg, heart rate in beats per minute greater than or equal to systolic blood pressure in millimeters of mercury, respiratory rate of >30 breaths per minute, or<unk> o2  of <90% while the patient was breathing ambient air)
repeat chest radiograph showed an enlarging pneumothorax along with physiological instability.
14 to 50 years of age
unilateral primary<unk>  of 32% or more on chest radiography according to the Collins method (sum of interpleural distances, >6 cm)
Secondary pneumothorax, defined as pneumothorax occurring in the setting of acute trauma (including iatrogenic) or underlying lung disease including but not limited to COPD, pulmonary fibrosis, TB, cystic fibrosis, lung cancer and asthma that requires regular preventative medication or has been symptomatic within the last two years
Previous<unk>  on the same side 3. Coexistent haemothorax (i.e.<unk> ontaneous haemopneumothorax)
Bilateral pneumothorax
Clinical instability suggesting tension pneumothorax; respiratory distress persisting despite oxygen and parenteral narcotic analgesia (RR >30/min or<unk> O2 <90%), SBP <90 mmHg, HR greater than or equal to SBP.
Pregnancy at time of enrolment
Social circumstances whereby the patient either does not have adequate support after discharge to re-attend hospital if required, or is unlikely to present for study follow up.
Air travel within the next 12 weeks if this cannot be deferred should the pneumothorax be slow to resolve"
clinically significant symptoms persisted despite adequate analgesia
chest pain or dyspnea prevented mobilization
patient was unwilling to continue with conservative treatment
the patient’s condition became physiologically unstable (systolic blood pressure of <90 mm Hg, heart rate in beats per minute greater than or equal to systolic blood pressure in millimeters of mercury, respiratory rate of >30 breaths per minute, or<unk> o2  of <90% while the patient was breathing ambient air)
repeat chest radiograph showed an enlarging pneumothorax along with physiological instability.
Admit with chest tube for thoracoscopy (VATS)^
^If thoracoscopy (VATS) is not readily available, chemical pleurodesis through the chest tube
Asymptomatic AND very small (<1 cm interpleural distance)
Observation with supplemental oxygen; repeat CXR in 12-24 hours
Asymptomatic AND small
Chest tube (some centers may choose needle aspiration under ultrasound guidance)
Observation alone associated with some mortality
Symptomatic OR large OR bilateral
Chest tube
Observation with supplemental oxygen; repeat CXR in 12-24 hours
Chest tube (some centers may choose needle aspiration under ultrasound guidance)
Observation alone associated with some mortality
Chest tube
Use thoracentesis or "pig-tail" kit, if available
Place in 2nd IC<unk> ace in midclavicular line or 4th/5th IC<unk> ace in anterior axillary line
Withdraw air with syringe until no more can be aspirated
Assume a persistent air leak (failure) if no resistance after 4 liters of air has been aspirated AND the lung has not expanded
Once no further air can be aspirated:
Option 1
Place closed stopcock and secure catheter to the chest wall
Obtain CXR four hours later
If adequate lung expansion has occurred, remove catheter
Following another two hours of observation, obtain another CXR
If the lung remains expanded, may discharge patient
Option 2
Leave catheter in place
Attached a Heimlich (one-way) valve
May discharge with follow-up within two days
If 2.5 L of air has been aspirated, and a significant PTX remains, tube thoracostomy is indicated
NEJM video on needle aspiration of pneumothorax.
Assume a persistent air leak (failure) if no resistance after 4 liters of air has been aspirated AND the lung has not expanded
Option 1
Place closed stopcock and secure catheter to the chest wall
Obtain CXR four hours later
If adequate lung expansion has occurred, remove catheter
Following another two hours of observation, obtain another CXR
If the lung remains expanded, may discharge patient
Option 2
Leave catheter in place
Attached a Heimlich (one-way) valve
May discharge with follow-up within two days
Place closed stopcock and secure catheter to the chest wall
Obtain CXR four hours later
If adequate lung expansion has occurred, remove catheter
Following another two hours of observation, obtain another CXR
If the lung remains expanded, may discharge patient
Leave catheter in place
Attached a Heimlich (one-way) valve
May discharge with follow-up within two days
Most<unk>  (primary and secondary)
Most iatrogenic pneumothorax
Alveolar-pleural fistulae (small air leak)
Iatrogenic air
Traumatic pneumothorax
Traumatic hemothorax ("any acute hemothorax visible on chest radiograph")
Pneumothorax on mechanical ventilation
Non-traumatic tension pneumothorax
Malignant effusion
Trauma/bleeding (hemothorax/hemopneumothorax)
Bronchial-pleural fistulae (large air leak)
Malignant fluid
Empyema
Thick pus
Spontaneous pneumothorax
Tension pneumothorax
Hemothorax
Catamenial pneumothorax
Traumatic pneumothorax
Chylothorax
Iatrogenic pneumothorax
Lung abscess