This document discusses the management of spontaneous pneumothorax. It provides guidelines for treating primary and secondary spontaneous pneumothorax, including observation for small pneumothoraces and chest tube insertion for large or unstable patients. Recent studies have found conservative management without intervention may be sufficient and safer than interventional treatment for moderate to large primary pneumothoraces. Needle aspiration appears to be as effective as small bore chest tubes with a lower risk of complications.

1. Spontaneous Pneumothorax
Elizabeth Olson, MD & Janet Lorenz, NP
Carolinas Medical Center & Levine Children’s Hospital
Charlotte, North Carolina
Michael Gibbs, MD, Faculty Editor
The Chest X-Ray Mastery Project™

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

3. Process
• Many are providing clinical cases and presentations are then shared with
all contributors on our departmental educational website.
• Contributors from many Carolinas Medical Center departments, and now…
Brazil, Chile, and Tanzania.
• We will review a series of CXR case studies and discuss an approach to the
diagnoses at hand: SPONTANEOUS PNEUMOTHORAX.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. 18-Year-Old With
Acute Pleuritic
Chest Pain.

8. Spontaneous Pneumothorax
18-Year-Old With
Acute Pleuritic
Chest Pain.

9. Young Healthy
Patient Presents
With Pleuritic
Chest Pain.

10. Left Spontaneous Pneumothorax
Young Healthy
Patient Presents
With Pleuritic
Chest Pain.

11. After Drainage
Young Healthy
Patient Presents
With Pleuritic
Chest Pain.

12. Healthy Young
Female With
Sudden Onset
Right-Sided
Pleuritic Chest
Pain.

13. Spontaneous Pneumothorax
Healthy Young
Female With
Sudden Onset
Right-Sided
Pleuritic Chest
Pain.

14. 20-Year-Old Male
Presents With
Sharp Chest Pain
And Shortness Of
Breath.

15. Left Spontaneous Pneumothorax
20-Year-Old Male
Presents With
Sharp Chest Pain
And Shortness Of
Breath.

16. After Drainage
Healthy Male
Presents With
Sharp Chest Pain
And Shortness Of
Breath.

17. Healthy Male
Presents With
Sharp Chest Pain.

18. Healthy Male
Presents With
Sharp Chest Pain.
Right Spontaneous Pneumothorax

19. Healthy Male
Presents With
Sharp Chest Pain.
After Drainage

20. Young, Healthy
Male Experiences
Acute Left-Sided
Chest Pain While
Running.

21. Young, Healthy
Male Experiences
Acute Left-Sided
Chest Pain While
Running.
Left Spontaneous Pneumothorax

22. Young, Healthy
Male Experiences
Acute Left-Sided
Chest Pain While
Running.
After Drainage

23. Sahn SA. NEJM 2000; 342:868-874.
Classification Of Pneumothorax According To Cause
Spontaneous
1°: No clinical lung disease
2°: A complication of clinically apparent lung disease
Traumatic
• Penetrating trauma
• Blunt trauma
Iatrogenic
• Transthoracic needle aspiration
• Central line placement
• Thoracentesis
• Lung biopsy

24. Primary Spontaneous Pneumothorax – although technically occurring in the
absence of clinical lung disease, much more common in smokers (including
marijuana smokers). Also more common in tall men.
Secondary Spontaneous Pneumothorax – most frequently due to COPD (57%);
other causes include asthma, PJP pneumonia, cystic fibrosis, malignancy, or TB.
Bintcliffe, O, & Maskell, N (2014). Spontaneous pneumothorax. BMJ. 2014; 348, g2928. doi: 10.1136/bmj.g2928

25. NEJM 2000; 342:868-874.

26. Steven A. Sahn, MD, FCCP; for theACCP Pneumothorax Consensus Group†
ovide explicit expert-based consensusrecommendationsfor the management of adultswith
econdaryspontaneouspneumothoracesinanemergencydepartment andinpatient hospital
se of opinion wasmade explicit by employing a structured questionnaire, appropriateness
onsensus scores with a Delphi technique. The guideline was designed to be relevant to
o make management decisionsfor the care of patientswith pneumothorax.
isions for observation, chest tube placement, surgical interventions, and radiographic
fectivenessof pneumothorax resolution, duration of and patient tolerance of care, and
x recurrence.
erature review from 1967 to January 1999 and Delphi questionnaire submitted in three
a multidisciplinary physician panel.
guideline development group determined by consensus the relevant outcomes to be
developing the Delphi questionnaire.
ms, and costs:The type and magnitude of benefits, harms, and costsexpected for patients
e implementation.
ions: Management decisions vary between patients with primary or secondary pneu-
with observation of small pneumothoracesbeing appropriate only for primary pneumo-
level of consensusvariesregarding the specific interventionsindicated, but agreement
general principles of care.
ecommendations were peer reviewed by physician experts and were reviewed by the
lege of Chest Physicians (ACCP) Health and Science Policy Committee.
on: The guideline recommendations will be published in printed and electronic form
ion of synopsesfor patientsand health care providers. Contentsof the guideline will be
into continuing medical education programs.
e ACCP. (CHEST 2001; 119:590–602)

27. Management Of Spontaneous Pneumothorax (PNTX)
Primary Spontaneous Pneumothorax:
Stable1, small PNTX Observe 4-6 hours, repeat CXR, consider discharge with close F/U
Stable1, large PNTX Needle or catheter aspiration or pigtail or chest tube insertion
Unstable patient2 Immediate pigtail/chest tube, if delayed needle or finger thoracostomy
Secondary Spontaneous Pneumothorax:
Stable1, small PNTX Admit for observation with treatment(s) based on progression
Stable1, large PNTX Pigtail or chest tube insertion
Unstable patient2 Immediate pigtail/chest tube, if delayed needle or finger thoracostomy
Steven A. Sahn, MD, FCCP; for theACCP Pneumothorax Consensus Group†
ovide explicit expert-based consensusrecommendationsfor the management of adultswith
econdaryspontaneouspneumothoracesinanemergencydepartment andinpatient hospital
se of opinion wasmade explicit by employing a structured questionnaire, appropriateness
onsensus scores with a Delphi technique. The guideline was designed to be relevant to
o make management decisionsfor the care of patientswith pneumothorax.
isions for observation, chest tube placement, surgical interventions, and radiographic
fectivenessof pneumothorax resolution, duration of and patient tolerance of care, and
x recurrence.
erature review from 1967 to January 1999 and Delphi questionnaire submitted in three
a multidisciplinary physician panel.
guideline development group determined by consensus the relevant outcomes to be
developing the Delphi questionnaire.
ms, and costs:The type and magnitude of benefits, harms, and costsexpected for patients
e implementation.
ions: Management decisions vary between patients with primary or secondary pneu-
with observation of small pneumothoracesbeing appropriate only for primary pneumo-
level of consensusvariesregarding the specific interventionsindicated, but agreement
general principles of care.
ecommendations were peer reviewed by physician experts and were reviewed by the
lege of Chest Physicians (ACCP) Health and Science Policy Committee.
on: The guideline recommendations will be published in printed and electronic form
ion of synopsesfor patientsand health care providers. Contentsof the guideline will be
into continuing medical education programs.
e ACCP. (CHEST 2001; 119:590–602)

28. Even Large Spontaneous PNTX May Not Require Intervention:

29. Conservative vs. Interventional Treatment
• Multicenter, randomized, non-inferiority trial evaluating the management
of moderate-to-large primary spontaneous pneumothoraces
• 316 patients total, randomized to either interventional treatment (154
pts) or conservative treatment (162 pts)
• Primary outcome: complete radiographic resolution within 8 weeks
Brown SGA. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med. 2020 Jan 30; 382(5): 405-415.
doi: 10.1056/NEJMoa1910775

30. Conservative vs. Interventional Treatment
Interventional treatment:
• Small-bore pigtail catheter (≤12 fr) inserted & placed to water seal
• Repeat CXR at 1 hr. If resolved, drain clamped & patient observed x 4 hrs
• If patient stable and repeat CXR without recurrence, drain removed and
patient discharged
• If not resolved on initial CXR or if recurrence of PNTX, patient admitted for
further care
Conservative treatment:
• Observed for 4 hrs; discharged if stable + not requiring O2 + tolerating
ambulation
Brown SGA. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med. 2020 Jan 30; 382(5): 405-415.
doi: 10.1056/NEJMoa1910775

31. Conservative vs. Interventional Treatment
• Results suggested that conservative treatment was not inferior to
interventional treatment
• Conservative treatment had a lower risk of adverse event and serious
adverse events
• Interestingly, the conservative group also had a lower risk of recurrence of
PNTX
Brown SGA. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med. 2020 Jan 30; 382(5): 405-415.
doi: 10.1056/NEJMoa1910775

33. Comparing Management Strategies
• Systematic review and network meta-analysis
• Evaluated 12 RCTs involving 781 patients. Compared needle aspiration,
small-bore chest tube (≤ 14 F), or large-bore chest tube (≥ 14 F) in terms
of effectiveness, efficiency, and safety
• Primary outcome: “Immediate success” of intervention
• Secondary outcomes: Efficiency (LOS) & safety (risk of complications)
Mummad SR. Comparative effectiveness of interventions in initial management of spontaneous pneumothorax: A systematic review and
a Bayesian network meta-analysis. Ann Emerg Med; 2020: 0(0), 1-15. https://doi.org/10.1016/j.annemergmed.2020.01.009

34. Comparing Management Strategies
Immediate success:
• A – Resolution of symptoms and radiographic resolution, sustained
for 6-24 h in the needle aspiration group
• B – Radiographic resolution, no air leak, and chest tube removal in
< 7 days in either size chest tube groups
• C – Ability to discharge patient from the ED in the needle
aspiration and small-bore chest tube group
Mummad SR. Comparative effectiveness of interventions in initial management of spontaneous pneumothorax: A systematic review and
a Bayesian network meta-analysis. Ann Emerg Med; 2020: 0(0), 1-15. https://doi.org/10.1016/j.annemergmed.2020.01.009

35. Comparing Management Strategies
• No difference in immediate success between large-bore chest tube,
small-bore chest tube, or needle aspiration
• Needle aspiration had similar rate of complications as small-bore chest
tube; significantly lower odds of complications seen with needle
aspiration than large-bore chest tube
• Small-bore chest tube most likely to be effective; needle decompression
safest
• No benefit of large-bore chest tube over small-bore chest tubes in the
management of symptomatic spontaneous PNTX
Mummad SR. Comparative effectiveness of interventions in initial management of spontaneous pneumothorax: A systematic review and
a Bayesian network meta-analysis. Ann Emerg Med; 2020: 0(0), 1-15. https://doi.org/10.1016/j.annemergmed.2020.01.009

36. If You Have Interesting Cases Of Spontaneous Pneumothorax, We Invite You
To Send A Set Of Digital PDF Images And A Brief Descriptive Clinical History To:
michael.gibbs@atriumhealth.org
Your De-Identified Case(s) Will Be Posted On Our Education Website And You
And Your Institution Will Be Recognized!