A spontaneous pneumothorax happens when air leaks into the space between the lung and the chest wall without any injury, so part of the lung collapses. Primary cases occur in tall, thin young adults who often smoke, and secondary cases occur in people with lung disease such as COPD.
Key symptoms
- Sudden, sharp one-sided chest pain, worse with breathing
- Shortness of breath
- Fast heart rate and anxiety
- Dry cough
What you find on exam
- Reduced or absent breath sounds on the affected side
- Hyperresonant percussion and less chest movement on that side
- Oxygen saturation, breathing rate and blood pressure
- Tension signs: low blood pressure, distended neck veins, trachea shifted away
Tests
- Upright chest X-ray: thin pleural line with no lung markings beyond it
- Bedside ultrasound: no lung sliding
- Chest CT for unclear or recurrent cases
- Blood gas in patients with underlying lung disease
Treatment basics
- Small, stable primary pneumothorax: oxygen and observation with a repeat X-ray
- Large or symptomatic: needle aspiration or a small-bore chest tube
- Tension pneumothorax: immediate needle decompression, then a chest tube
- Surgery (VATS with pleurodesis) for recurrence or a persistent air leak
- Stop smoking; avoid flying and diving until healed
Red flags
- Low blood pressure, distended neck veins or shifted trachea
- Worsening breathlessness or falling oxygen
- Pneumothorax in a patient with COPD or on a ventilator
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; NASEMSO National Model EMS Clinical Guidelines. Written by Making Synapses. Making Synapses is not affiliated with these organizations.