Our approach to the initial treatment of primary spontaneous pneumothorax

This figure summarizes our suggested approach to the management of patients with PSP. PSP is pneumothorax without underlying lung disease or trauma. This algorithm assumes that the patient has been adequately treated with analgesia. If at any point during the evaluation, patients develop instability due to pneumothorax, chest tube or needle thoracostomy should be performed. Catheter aspiration is the direct aspiration of air using a catheter attached to a syringe that is not typically attached to a drainage system; it is usually removed after a few hours but may be modulated to attach to a drainage system if needed. Catheter or chest tube thoracostomy refers to a catheter or chest tube that remains in place in the pleural space (usually for a few days) and is typically attached to a drainage system. This algorithm is intended for use in conjunction with additional UpToDate content. For additional details, including the evidence supporting the efficacy of these strategies, refer to UpToDate content on PSP.

PSP: primary spontaneous pneumothorax; SpO₂: peripheral oxygen saturation.

* Most clinicians insert the chest tube via an incision at the fourth or fifth intercostal space in the anterior axillary or midaxillary line. Clinicians generally prefer a small-bore chest tube (≤22 French) or chest catheter (≤14 French). For the majority of patients, suction is not initially applied and the tube or catheter is connected to a water seal device only. Admission is required.

¶ The assessment of dyspnea is highly subjective and there are no useful criteria to distinguish minimal from significant dyspnea. Thus, clinicians should use their clinical judgement for this evaluation.

Δ Humidified high flow oxygen delivered via nasal cannula or noninvasive mechanical ventilation should not be used due to the positive pressure associated with these devices.

◊ Some clinicians choose catheter or chest tube thoracostomy when expertise in aspiration is not available. Discharge with a one-way valve is also an option if the patient meets discharge criteria.

§ As an alternative to catheter or chest tube thoracostomy, some clinicians leave the catheter in place and attach it to a one-way valve (eg, Heimlich valve). The patient can then be discharged with clinical and radiographic follow-up within 1 to 2 days, provided they have good access to medical services. If follow up imaging demonstrates recurrence, then a catheter or chest tube thoracostomy should be placed. If follow up imaging indicates resolution, then the catheter and valve can be removed.

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Our approach to the initial treatment of primary spontaneous pneumothorax