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Overview and Recommendations
Background
- •Define pneumothorax as the presence of air between the visceral and parietal pleura, which disrupts the negative pressure required for lung expansion and can lead to cardiovascular impairment.
- •Distinguish between primary spontaneous pneumothorax (PSP), occurring in patients without overt lung disease (often tall, thin male smokers), and secondary spontaneous pneumothorax (SSP), which complicates existing conditions like , , or .
- •Recognize the genetic risk associated with (BHDS), an autosomal dominant condition caused by FLCN gene mutations that leads to pulmonary cysts and a nearly 60% lifetime risk of spontaneous pneumothorax.
- •Identify iatrogenic triggers, including CT-guided lung biopsies (up to 43% risk for small nodules), central line placement, and mechanical ventilation, which can cause barotrauma and rapid progression to tension physiology.
- •Understand the 'buffalo chest' phenomenon, an iatrogenic or congenital communication between the two pleural cavities (often seen after repair) that allows a unilateral air leak to become a life-threatening bilateral pneumothorax.
- •Differentiate simple pneumothorax from , where increasing intrapleural pressure shifts the mediastinum and compresses the vena cava, leading to decreased venous return and obstructive shock.
Evaluation
- •Suspect pneumothorax in any patient presenting with sudden-onset pleuritic chest pain and dyspnea, particularly if symptoms began at rest or following a thoracic procedure.
- •Examine the patient for classic physical findings, including diminished or absent breath sounds on the affected side, hyper-resonance (tympany) on percussion, and decreased tactile fremitus.
- •Monitor vital signs closely for 'red flags' of tension physiology: tachycardia, hypotension, SpO2 < 90%, and tracheal deviation away from the affected side.
- •Obtain an upright posteroanterior (PA) chest X-ray as the first-line diagnostic study to identify the visceral pleural line and the absence of peripheral lung markings.
- •Utilize point-of-care ultrasound (POCUS) in emergency or trauma settings to look for the 'lung point' sign (100% specific for pneumothorax) and the absence of 'lung sliding' or 'B-lines'.
- •Measure the size of the pneumothorax using the British Thoracic Society (BTS) criteria (large = ≥2 cm rim of air at the level of the hilum) or the American College of Chest Physicians (ACCP) criteria (large = ≥3 cm at the apex).
- •Identify the 'deep sulcus sign' on supine chest radiographs in trauma patients, characterized by an abnormally deep and radiolucent costophrenic angle.
- •Rule out mimics such as giant pulmonary bullae, which typically have a concave inner border, and diaphragmatic hernia, which may show bowel loops in the thoracic cavity (pseudotension pneumothorax).
- •Consider specialized imaging like MRI for suspected catamenial pneumothorax (related to ) if symptoms recur in sync with the menstrual cycle.
- •Screen for underlying systemic diseases in patients with recurrent or bilateral episodes, including (LAM) in females or BHDS in those with a family history of renal tumors.
Management
- •Administer supplemental oxygen (high-flow) to all patients requiring intervention, as this increases the rate of pleural air absorption by fourfold by reducing the partial pressure of nitrogen.
- •Manage stable patients with a small PSP (<2 cm) conservatively with observation and a repeat chest X-ray in 6–24 hours; discharge is appropriate if the pneumothorax is stable and follow-up is guaranteed.
- •Perform simple aspiration using a 16–18G cannula for large PSPs in stable patients; this is often better tolerated than chest tube insertion and may avoid hospitalization.
- •Insert a small-bore chest tube (10–14 Fr) for patients with SSP, failed aspiration, or those who are symptomatic and unstable.
- •Perform immediate needle decompression for suspected using a 14G needle in the 2nd intercostal space (midclavicular line) or the 4th/5th intercostal space (anterior axillary line) before waiting for imaging.
- •Apply low-pressure negative suction (-20 cmH2O) if the lung fails to re-expand after 24–48 hours of water seal drainage or if a large air leak is present.
- •Monitor for re-expansion pulmonary edema (RPE) when draining a lung that has been collapsed for >72 hours; avoid high-volume suction initially in these chronic cases.
- •Consult thoracic surgery for a persistent air leak (PAL) lasting more than 5–7 days, or for recurrent, bilateral, or high-risk occupational (e.g., divers, pilots) pneumothoraces.
- •Consider an autologous blood patch (50–100 mL of the patient's blood instilled via chest tube) or endobronchial valves for patients with PAL who are not candidates for surgery.
- •Implement Respiratory Training-Based Rehabilitation (RTBR) post-procedure to improve FEV1 and reduce the duration of hospitalization.
- •Remove the chest tube only after the air leak has ceased (no bubbling in the water seal) and the lung remains fully expanded on a trial of water seal for 4–24 hours.
- •Advise patients to avoid air travel until at least 1–2 weeks after radiographic resolution has been confirmed, as hypobaric conditions can cause residual air to expand.
- •Counsel all patients on permanent smoking cessation, as continued tobacco or cannabis use significantly increases the risk of recurrence.
- •Refer patients with suspected genetic syndromes (e.g., BHDS) for genetic counseling and screening for associated visceral malignancies like renal cell carcinoma.
Board Review — High Yield
- •Lung point — The most specific ultrasound sign for pneumothorax; represents the physical transition between collapsed and inflated lung.
- •Deep sulcus sign — An abnormally deep, radiolucent costophrenic angle on a supine CXR, indicating pneumothorax in trauma patients.
- •Birt-Hogg-Dubé syndrome — FLCN mutation; triad of spontaneous pneumothorax, fibrofolliculomas, and renal cell carcinoma.
- •Catamenial pneumothorax — Recurrent pneumothorax occurring within 72 hours of menses onset; caused by thoracic endometriosis.
- •Re-expansion pulmonary edema — A potential complication of rapid re-inflation of a lung that has been collapsed for more than 3 days.
- •Buffalo chest — A rare condition where the pleural spaces communicate, leading to bilateral collapse from a single-sided air leak.
- •Spiked helmet sign — An ECG pattern (ST-elevation with dome-and-spike) that can be seen in pneumothorax and mimics MI.
- •Vaping-associated spontaneous pneumothorax (VASP) — An emerging entity in young patients using electronic cigarettes or cannabis concentrates.
Deep Dive — Evidence Details
Definition, Synonyms, and Classification
- ▸Pneumothorax is defined as air in the pleural space and is classified primarily by etiology (spontaneous, traumatic, iatrogenic) and physiological impact (simple vs. tension) [5].
- ▸Tension pneumothorax is a life-threatening emergency characterized by expanding air volume and pressure leading to obstructive shock, often exacerbated by positive pressure ventilation [5].
- ▸Secondary spontaneous pneumothorax can be a manifestation of Birt-Hogg-Dubé syndrome, linked to mutations in the FLCN gene which predisposes individuals to lung cysts [3].
A pneumothorax is defined as the presence of air within the , the potential space between the visceral and parietal pleura [5]D. This accumulation of air disrupts the negative pressure required for normal lung expansion, potentially leading to partial or complete lung collapse. While often occurring as a primary event, it is frequently a complication of underlying pulmonary pathology, trauma, or medical intervention [3]D[5]D.
Synonyms and Alternate Nomenclature
In clinical practice, several terms are used interchangeably or to describe specific presentations of the condition. Standardized nomenclature is essential for clear communication between clinicians, particularly in emergency and neonatal intensive care settings [2]D[6]D.
- Also Called: PTX, collapsed lung, or air in the chest.
- Simple Pneumothorax: A pneumothorax that does not result in significant mediastinal shift or hemodynamic instability [5]D.
- : A life-threatening variant where air enters the pleural space but cannot escape, leading to progressively increasing intrapleural pressure [5]D.
- Spontaneous Pneumothorax: A pneumothorax occurring without an external provocative factor, further divided into primary and secondary types [3]D.
- Iatrogenic Pneumothorax: A pneumothorax resulting from a medical procedure, such as a biopsy or injection [1]D[4]D.
Key Definitions and Clinical Phases
Understanding the progression of a pneumothorax is critical for determining the urgency of intervention. The condition is often described through various phases and clinical states:
- Prodromal/Initial Phase: The period immediately following the initial air leak into the pleural space. In spontaneous cases, this may be associated with the rupture of subpleural blebs or cysts, such as those seen in [3]D.
- Progressive Phase: The stage where the volume of air in the pleural space increases. This is particularly dangerous in patients receiving positive pressure ventilation (PPV), as the ventilator can exacerbate the air leak and accelerate the transition from a simple to a tension state [5]D.
- Nadir: The point of maximal lung collapse and physiological impairment before intervention.
- Tension State: A critical physiological state where expanding air volume and pressure result in obstructive shock [5]D. This occurs because the high intrapleural pressure impairs venous return to the heart.
- Plateau: A stable state where the air leak has ceased and the volume of intrapleural air remains constant.
- Recovery Phase: The period following successful intervention (e.g., or chest drainage) where the lung re-expands and the pleural layers appose [6]D.
Classification of Pneumothorax Types
Pneumothorax is classified based on its etiology and the presence or absence of underlying lung disease. Standardized classification systems, such as the Common Terminology for Clinically Adverse Events (CTCAE), are often used to grade the severity of iatrogenic cases [4]D.
Spontaneous Pneumothorax and Genetic Predisposition
Spontaneous pneumothorax is categorized into primary (PSP) and secondary (SSP). PSP occurs in individuals without clinically apparent lung disease, while SSP occurs as a complication of an existing condition. A notable cause of SSP is Birt-Hogg-Dubé syndrome (BHDS), an autosomal dominant condition caused by mutations in the folliculin (FLCN) gene [3]D.
In BHDS, the development of lung cysts predisposes patients to spontaneous pneumothorax. The FLCN gene encodes a 579-amino acid protein that is highly conserved across species; mutations in this gene have a detection rate of approximately 88% in affected families [3]D. This highlights the importance of genetic screening in patients with recurrent or familial spontaneous pneumothorax.
Traumatic and Iatrogenic Classifications
Traumatic pneumothorax results from blunt or penetrating chest injury and is common in both civilian and military environments [5]D. Iatrogenic pneumothorax is a subset of traumatic pneumothorax caused by medical procedures. For example, image-guided core needle biopsies for suspected carry a risk of pneumothorax, which must be documented using standardized nomenclature to track procedural safety [4]D. Even seemingly minor procedures, such as trigger point injections (TPIs) for headache disorders, carry a theoretical risk of iatrogenic pneumothorax if the needle penetrates the pleura [1]D.
Size-Based and Physiological Classifications
While clinical nomenclature often focuses on the mechanism (e.g., traumatic vs. spontaneous), the physiological impact is the primary driver of . The distinction between a simple and a tension pneumothorax is the most critical classification in emergency medicine [5]D.
- Simple: Air is present, but the pressure does not exceed atmospheric pressure throughout the respiratory cycle.
- Tension: A "one-way valve" mechanism allows air to enter the pleural space during inspiration but prevents its egress during expiration. This leads to a rapid rise in pressure, mediastinal shift, and eventual cardiovascular collapse [5]D.
Clinicians also utilize to classify findings based on specific artifacts, such as the presence or absence of "lung sliding," which is a key diagnostic marker in the differential algorithm for acute dyspnea [6]D.
| Variant Name | Key Distinguishing Feature | Associated Factors/Genetics |
|---|---|---|
| Primary Spontaneous (PSP) | Occurs without underlying lung disease or trauma | Often associated with subpleural blebs |
| Secondary Spontaneous (SSP) | Occurs in the presence of underlying lung disease | FLCN gene mutations (Birt-Hogg-Dubé) [3]D |
| Traumatic | Result of blunt or penetrating chest injury | Common in civilian and military trauma [5]D |
| Iatrogenic | Result of medical procedures (biopsy, TPI) | Documented via CTCAE nomenclature [1]D[4]D |
| Tension | Expanding pressure causing obstructive shock | One-way valve mechanism; exacerbated by PPV [5]D |
Epidemiology and Risk Factors
- ▸Birt-Hogg-Dubé syndrome carries the highest genetic risk for spontaneous pneumothorax, with a prevalence of 59%.
- ▸Iatrogenic pneumothorax occurs in up to 43% of CT-guided biopsies for small pulmonary nodules, with COPD being a major independent risk factor (OR 3.453).
- ▸Pneumothorax is a common 'intended' or expected complication of endobronchial valve treatment, occurring in approximately one-quarter of patients.
The of pneumothorax is characterized by a bimodal distribution, distinguishing between primary spontaneous pneumothorax (PSP), which typically affects young, healthy individuals, and secondary spontaneous pneumothorax (SSP), which occurs in the context of underlying pulmonary pathology. Iatrogenic and traumatic etiologies represent a significant and increasing proportion of cases due to the expansion of invasive diagnostic and therapeutic interventions [18][29]D.
Spontaneous Pneumothorax: Incidence and Demographics
Spontaneous pneumothorax (SP) prevalence varies significantly based on genetic and environmental predispositions. In patients with diffuse cystic lung diseases (DCLDs), the overall prevalence of SP is approximately 31% [35]D. However, this risk is highly disease-specific. Patients with (BHD) exhibit the highest risk, with a pooled prevalence of spontaneous pneumothorax reaching 59% [7][35]D. Other cystic pathologies also show high rates: (LAM) has a prevalence of 34% (exclusively in females), and (PLCH) has a prevalence of 36% [35]D. In contrast, conditions like Sjögren's syndrome-associated cystic lung disease show negligible SP risk [35]D.
In the neonatal population, pneumothorax is a critical complication of prematurity. Among very preterm infants (gestational age 24–31 weeks), the incidence is approximately 1.2% [36]. This is often associated with surfactant deficiency and the mechanical stresses of neonatal intensive care.
Risk Factors for Spontaneous Pneumothorax
The development of SP is driven by a combination of anatomical, behavioral, and genetic factors. While cigarette smoking is a classic risk factor, electronic cigarette use (vaping) has emerged as a significant modern contributor, though its exact relative risk remains under investigation through case series [12].
- Anatomical and Genetic Factors: Patients with undergoing minimally invasive repair (MIRPE) are at unique risk. These patients often possess congenital apical blebs, and the surgical procedure can create a "buffalo chest"—an iatrogenic communication between pleural cavities—leading to potentially life-threatening bilateral pneumothorax [11].
- Infection: Spontaneous pneumothorax has been frequently reported in non-vaccinated patients with , complicating survival rates and hospital [16].
- Environmental Triggers: Environmental factors, including atmospheric pressure changes and air pollutants, have been implicated in the onset of both initial PSP and postoperative recurrence [27]D.
Iatrogenic and Procedure-Related Risk
Iatrogenic pneumothorax is a common complication of modern thoracic interventions. The risk is particularly high in the following scenarios:
- CT-Guided Lung Biopsy: The incidence of pneumothorax following percutaneous core needle biopsy of small nodules (≤1.5 cm) is as high as 43% [18]. Risk factors include a transpulmonary needle path and underlying (OR 3.453) [18].
- Endobronchial Valve (EBV) Treatment: Used for severe emphysema, EBV placement carries a pneumothorax risk of 20.2% to 25.4% [15][28]D. The risk is significantly higher when the target for treatment is the upper lobes [15].
- Mechanical Ventilation: In patients with (ALS) on mechanical ventilation, the incidence of pneumothorax is approximately 20% (19 out of 95 patients) [21]D.
- Diaphragmatic Surgery: In advanced ovarian cancer cytoreduction, diaphragmatic resection or stripping frequently results in pneumothorax as a short-term postoperative complication [30]D[34]D.
Risk Mitigation Protocol for Lung Biopsy
To reduce the incidence of iatrogenic pneumothorax during CT-guided procedures, clinicians may employ the following evidence-based steps:
- Step 1: Assess patient positioning. Utilizing the "gravitational effect" by adjusting the relative height of the entry point can influence pleural pressure and reduce air leak risk [31]D.
- Step 2: Consider the use of the PEARL (Percutaneous Aggregated technique for multiple samplings) approach, which has been validated to decrease pneumothorax rates across multiple centers [33]D.
- Step 3: Implement track sealing. Subpleural injection of gelatin sponge particles or slurry upon needle withdrawal significantly reduces the incidence of post-biopsy pneumothorax [17][25]D.
Risk Factor Summary Table
| Risk Factor | Odds Ratio (OR) / Prevalence | Evidence Level |
|---|---|---|
| Birt-Hogg-Dubé Syndrome | 59% Prevalence | 2a [7][35]D |
| COPD (in CT-guided biopsy) | OR 3.453 | 2b [18] |
| Endobronchial Valve (EBV) | 20.2%–25.4% Incidence | 2b [15][28]D |
| Small Nodule Biopsy (≤1.5cm) | 43% Incidence | 2b [18] |
| Very Preterm Birth (24-31w) | 1.2% Incidence | 2b [36] |
| Mechanical Ventilation (ALS) | 20% Incidence | 5 [21]D |
| Disease Entity | Prevalence of Pneumothorax | Reference |
|---|---|---|
| Birt-Hogg-Dubé (BHD) | 59% | [35]D |
| Pulmonary Langerhans Cell Histiocytosis (PLCH) | 36% | [35]D |
| Lymphangioleiomyomatosis (LAM) | 34% | [35]D |
| Overall DCLD Cohort | 31% | [35]D |
Etiology and Triggering Factors
- ▸Spontaneous pneumothorax is increasingly categorized by the PLEX system (Pattern, Location, Extent, eXpected outcome) to guide surgical management beyond the simple primary/secondary distinction [47].
- ▸Iatrogenic triggers, specifically CT-guided biopsies and endobronchial valve placement, carry high complication rates (up to 43% and 34% respectively), necessitating specific preventative protocols like needle tract embolization [18, 25, 44].
- ▸Genetic screening for Birt-Hogg-Dubé or Marfan syndrome is essential in patients with familial clustering or recurrent episodes due to underlying collagen or elastin deficiencies [38].
Pneumothorax results from the breach of the visceral or parietal pleura, allowing air to enter the pleural space and disrupt the negative intrapleural pressure required for lung expansion [10][42]D. This condition is broadly classified into spontaneous (primary or secondary), traumatic, and iatrogenic categories, each driven by distinct pathophysiological mechanisms ranging from genetic collagen defects to procedural complications [38]D[47]D.
Spontaneous Pneumothorax: Primary and Secondary
Primary spontaneous pneumothorax (PSP) occurs in individuals without clinically apparent lung disease. The primary mechanism involves the rupture of subpleural blebs or bullae, often located at the lung apices [11]. While the exact cause of these blebs is debated, they are frequently associated with a tall, thin body habitus and smoking [12][24]D. Vaping has emerged as a significant modern trigger, with electronic cigarette use linked to acute lung injury and subsequent pleural air leaks [12]. Environmental factors also play a role; fluctuations in atmospheric pressure and temperature have been shown to trigger PSP episodes and increase the risk of postoperative recurrence [27]D.
Secondary spontaneous pneumothorax (SSP) occurs as a complication of underlying parenchymal disease. The most common cause is Chronic Obstructive Pulmonary Disease ( ), where emphysematous bullae rupture due to increased alveolar pressure or weakened lung architecture [18][23]D. (ILD) is another major contributor, characterized by fibrotic, noncompliant lung tissue that is prone to air leaks [23]D[47]D. The PLEX Classification (Pattern, Location, Extent, eXpected complexity) has been proposed to better categorize these variants: Type I (apical vulnerability), Type II (multibullous), Type III (emphysematous), and Type IV (fibrotic) [47]D.
Iatrogenic and Procedural Triggers
Iatrogenic pneumothorax is an increasingly common complication of diagnostic and therapeutic interventions.
- CT-Guided Lung Biopsy: This is a high-risk procedure, particularly for small pulmonary nodules (≤1.5 cm), where the incidence of pneumothorax can reach 43% [18]. Risk is further increased by a transpulmonary needle path and lower CT attenuation values along the needle track [18][39]. The use of gelatin sponge slurry to seal the needle tract is a preventative protocol used to reduce these rates [25]D.
- Endobronchial Valves (EBV): Used for lung volume reduction in emphysema, EBVs carry a pneumothorax risk of 20.2% to 34% [15][44]D. The mechanism involves rapid volume loss in the treated lobe, which increases parenchymal stress on the adjacent untreated lobes. Risk is significantly higher when valves are placed in the upper lobes [15].
- Mechanical Ventilation: Positive pressure ventilation can cause barotrauma, especially in vulnerable populations such as those with Amyotrophic Lateral Sclerosis (ALS) or severe [21]D[45]D. In ALS patients, the incidence of pneumothorax during mechanical ventilation is approximately 14.5%, often occurring within the first year of ventilation [21]D.
- Surgical Complications: Minimally invasive repair of (MIRPE) can create a "buffalo chest," an iatrogenic communication between pleural cavities that allows a unilateral leak to become a life-threatening bilateral pneumothorax [11]. Other triggers include central line insertion (e.g., subclavian vein catheterization) and lung transplantation, where pleural space complications occur in 58.8% of recipients [20]D[40]C.
Traumatic and Mechanical Factors
Traumatic pneumothorax results from blunt or penetrating chest wall injuries. Blunt trauma, such as that sustained in motor vehicle accidents, often involves rib fractures that lacerate the visceral pleura [19]D[41]C.
Protocol for Post-Traumatic Monitoring:
- Initial Assessment: Identify rib fractures or penetrating wounds via ATLS primary survey [37][41]C.
- Radiographic Follow-up: Patients with ≥3 rib fractures or associated require outpatient chest radiography within 30 days post-discharge to detect delayed pneumothorax [19]D.
- Intervention: Immediate needle decompression is indicated for tension physiology, followed by tube thoracostomy [37].
Genetic and Systemic Predispositions
Genetic factors significantly influence the risk of spontaneous pneumothorax, often through the disruption of connective tissue integrity [38]D.
- Birt-Hogg-Dubé (BHD) Syndrome: Caused by mutations in the FLCN gene, leading to multiple lung cysts and a high risk of spontaneous air leaks [38]D.
- Connective Tissue Disorders: , vascular Ehlers-Danlos syndrome (vEDS), and involve molecular defects in collagen or elastin, weakening the pleural surface [38]D.
- Drug-Induced Mechanisms: Fluoroquinolones have been associated with spontaneous pneumothorax due to their inhibitory effect on collagen synthesis and increased matrix metalloproteinase activity, which degrades pulmonary connective tissue [46]D. Paraquat ingestion causes rapid pulmonary fibrosis, which can lead to secondary air leaks [40]C.
Infectious and Environmental Triggers
Infectious pneumonia, particularly COVID-19, has been identified as a potent trigger for spontaneous pneumothorax [16][45]D. The mechanism involves diffuse alveolar damage and the formation of subpleural cysts that rupture under the stress of coughing or non-invasive ventilation (NIV) [26]D[45]D. In very preterm infants (24-31 weeks gestation), neonatal respiratory distress syndrome and its are primary triggers, with an incidence of 1.2% [36].
Differential Etiology: Pseudotension Pneumothorax
Clinicians must distinguish true from "pseudotension" triggers to avoid iatrogenic injury from unnecessary needle decompression [43]D. Common mimics include:
- Diaphragmatic Hernia (60% of cases): Abdominal contents in the thorax [43]D.
- Giant Pulmonary Bullae: Large air-filled spaces that mimic a collapsed lung [43]D.
- Cystic Lung Lesions: Congenital or acquired cysts [43]D.
| Cause | Category | Mechanism | Frequency/Risk | Key Reference |
|---|---|---|---|---|
| Apical Blebs/Bullae | Primary Spontaneous | Rupture of subpleural air spaces | Most common (PSP) | [11][24]D |
| COPD/Emphysema | Secondary Spontaneous | Rupture of emphysematous bullae | High in elderly | [18][23]D |
| CT-Guided Biopsy | Iatrogenic | Direct pleural puncture | 43% (small nodules) | [18][39] |
| Endobronchial Valves | Iatrogenic | Parenchymal stress/volume shift | 20.2% - 34% | [15][44]D |
| COVID-19 | Infectious | Alveolar damage/cyst rupture | Variable | [16][45]D |
| Fluoroquinolones | Drug-Induced | Collagen degradation | Increased OR | [46]D |
| Birt-Hogg-Dubé | Genetic | FLCN mutation/lung cysts | Rare/Familial | [38]D |
| Rib Fractures | Traumatic | Visceral pleura laceration | Common in trauma | [19]D |
| MIRPE (Pectus Repair) | Iatrogenic | "Buffalo chest" communication | Rare/Life-threatening | [11] |
History and Physical Examination
- ▸The classic triad of diminished breath sounds, hyper-resonance, and decreased tactile fremitus has limited sensitivity; POCUS is often superior to auscultation in noisy or emergency settings [48, 62].
- ▸A 'large' primary spontaneous pneumothorax is defined by a visible rim **≥2 cm** at the level of the hilum [51].
- ▸Clinicians must maintain high suspicion for pneumothorax in ALS patients and those with severe pectus excavatum, as these populations have shared risk factors for bleb formation [53, 67].
The clinical presentation of ranges from asymptomatic incidental findings to life-threatening respiratory failure. A high index of suspicion is required, particularly in patients with pre-existing lung disease or those who have undergone recent thoracic or upper extremity procedures [51][55]C[70]C.
Presenting Symptoms
The hallmark of spontaneous pneumothorax is the sudden onset of symptoms, typically occurring at rest [58]C[60]D.
- Chest Pain: Pleuritic chest pain is the most common symptom, reported in the majority of cases [51][73]C. It is usually sharp, unilateral, and localized to the side of the collapse. In some instances, such as right-sided pneumothorax, the pain may mimic other emergencies like myocardial infarction or pulmonary embolism [73]C.
- Dyspnea: Shortness of breath often accompanies chest pain. The severity of dyspnea is frequently proportional to the size of the pneumothorax and the patient's baseline pulmonary reserve [51][58]C. In patients with , sudden worsening of dyspnea may be the only indicator of a secondary spontaneous pneumothorax [54][58]C.
- Cough: A dry, non-productive cough may be present [59]C[60]D.
Symptoms typically reach their peak at onset and may stabilize, though they rarely resolve without intervention in large collapses. In iatrogenic cases, such as following shoulder arthroscopy or brachial plexus blocks, symptoms may be delayed by several hours or even up to 2 days post-procedure [55]C[70]C.
Physical Examination Findings
A systematic approach to the thoracic examination is essential, though clinicians must recognize that classic physical signs have limited sensitivity, particularly for small or occult pneumothoraces [48][61]D[62]D.
Step-by-Step Clinical Assessment Protocol
- Initial Inspection: Assess for signs of respiratory distress, including tachypnea, use of accessory muscles, and cyanosis. Observe for chest wall asymmetry or localized swelling, which may indicate [56]C[74]C.
- Palpation: Evaluate for tracheal deviation (a late sign of tension physiology). Palpate the chest wall for crepitus, suggesting air tracking into the soft tissues [56]C. Assess tactile fremitus, which is typically decreased or absent over the affected area [75]C.
- Percussion: Perform bilateral percussion. Hyper-resonance (tympany) is expected over the pleural air collection, though this may be difficult to appreciate in noisy clinical environments [75]C.
- Auscultation: Listen for diminished or absent breath sounds on the affected side [48][58]C[72]C. In the helicopter emergency medical services (HEMS) or trauma setting, auscultation is notoriously unreliable due to ambient noise; thoracic point-of-care ultrasound (POCUS) is often preferred for its superior diagnostic accuracy [48].
- Vital Sign Monitoring: Monitor for tachycardia and hypotension, which may signal the development of a [58]C[71]C.
Phenotypic Variants
Pneumothorax presents differently depending on the underlying etiology and patient population.
| Variant | Key Features | Frequency |
|---|---|---|
| Primary Spontaneous (PSP) | Occurs in healthy individuals without known lung disease; often tall, thin males [51][60]D. | Common in adolescents/young adults [75]C. |
| Secondary Spontaneous (SSP) | Occurs due to underlying lung disease (e.g., , , ) [53][54]. | Varies by underlying condition. |
| Traumatic | Result of blunt or penetrating chest trauma; may involve tracheobronchial injury [56]C[62]D. | 0.5–2% of trauma cases [56]C. |
| Iatrogenic | Follows procedures like MIRPE, shoulder surgery, or central line placement [11][49][55]C. | Rare but recognized complication [55]C. |
| Catamenial | Associated with ; occurs in relation to the menstrual cycle [52]. | Rare; most common extra-pelvic manifestation [52]. |
Red Flags
Certain findings necessitate immediate intervention before definitive imaging is obtained:
- Tension Physiology: Characterized by severe respiratory distress, SpO2 < 90% (sometimes as low as 75%), hypotension, and tracheal deviation away from the affected side [58]C[71]C.
- Massive Subcutaneous Emphysema: Rapidly progressing air in the soft tissues of the neck and chest, often associated with tracheobronchial injury [56]C.
- Bilateral Collapse: Rare but life-threatening; may occur in "buffalo chest" syndrome following MIRPE, where iatrogenic communication between pleural spaces exists [11][58]C.
Atypical Presentations
- Occult Pneumothorax: Air seen only on CT and not on initial chest X-ray. This is common in pediatric trauma and may be managed conservatively if the patient is stable [61]D.
- ALS Patients: Pneumothorax is often under-recognized in (ALS) because symptoms like dyspnea are attributed to baseline neuromuscular weakness [53][21]D.
- : Patients with a Haller Index > 3.615 have a significantly higher risk of bleb formation and subsequent spontaneous pneumothorax [67]D.
- Anesthesia-Related: During general anesthesia, a sudden increase in airway pressure or unexplained desaturation may be the only sign of an intraoperative tension pneumothorax [57]C[71]C.
| Diagnostic Tool | Sensitivity | Specificity | Clinical Context |
|---|---|---|---|
| Auscultation | Low | Moderate | Limited by ambient noise [48] |
| Thoracic POCUS | High | High | Preferred in HEMS/Trauma [48] |
| Chest X-ray | Moderate | High | May miss occult PTX [61]D |
| Chest CT | Gold Standard | Gold Standard | Identifies occult PTX [61]D[63]D |
Differential Diagnosis
- ▸Giant pulmonary bullae and diaphragmatic hernias are the most common causes of 'pseudotension pneumothorax' and must be ruled out via CT before invasive decompression in stable patients.
- ▸Thoracic endometriosis should be the primary differential for recurrent pneumothorax in females of reproductive age, particularly if symptoms are catamenial.
- ▸ECG changes like the 'spiked helmet sign' or ST-elevation can occur in pneumothorax, potentially leading to a misdiagnosis of myocardial infarction.
The differential diagnosis of pneumothorax is broad, encompassing common cardiopulmonary emergencies and rare systemic diseases. Accurate differentiation is critical because misidentifying a mimic as a can lead to unnecessary and potentially harmful interventions, such as needle decompression or chest tube insertion into a giant bulla or herniated abdominal organ [43]D[85]C.
Pulmonary Mimics and Cystic Lung Diseases
Giant pulmonary bullae and bullous emphysema are the most frequent mimics of pneumothorax on imaging [76][85]C. A giant pulmonary bulla can occupy more than 30-50% of the hemithorax, appearing as a large air-filled space that lacks peripheral lung markings [85]C. Unlike a pneumothorax, where the visceral pleural line is displaced toward the hilum, a bulla typically has a concave inner border and may show thin septations [85]C. On lung ultrasound, bullous emphysema may lack the "lung sliding" sign, mimicking pneumothorax; however, the presence of specific sonographic artifacts or a "lung point" can help differentiate the two [76].
Cystic lung diseases often present with spontaneous pneumothorax and must be considered in specific populations:
- Langerhans Cell Histiocytosis (LCH): Should be suspected in children or young adults presenting with recurrent, often bilateral, spontaneous pneumothoraces [79]C.
- Lymphangioleiomyomatosis (LAM): A primary consideration in females of childbearing age, particularly those with a history of renal masses (angiomyolipomas) or progressively worsening dyspnea [90]C.
- Birt-Hogg-Dubé Syndrome: Suggested by recurrent pneumothoraces in patients with a family history of the condition or characteristic skin lesions [88]C.
- Nodular Pulmonary Amyloidosis: A rare metabolic disorder where protein misfolding leads to cystic or nodular deposits that can rupture, causing pneumothorax [80]C.
- Mesenchymal Cystic Hamartoma: A rare, often indolent tumor composed of primitive mesenchymal cells and cystic spaces that can present as a sudden pneumothorax in adults [100]C.
and Diaphragmatic Mimics
Diaphragmatic hernia (DH), including late-presenting congenital Bochdalek hernias, can mimic the radiographic appearance of a tension pneumothorax [92]C. In these cases, herniated stomach or bowel loops filled with air appear as radiolucent areas in the hemithorax [43]D. This is termed pseudotension pneumothorax [43]D. A catastrophic variant is tension faecopneumothorax, where a missed diaphragmatic injury leads to bowel herniation, perforation, and the release of gas and feces into the pleural cavity, causing cardiovascular collapse [99]D.
Cardiac and Vascular Mimics
Pneumothorax can present with electrocardiographic (ECG) changes that mimic acute myocardial infarction (MI). The spiked helmet sign—a pattern of ST-segment elevation with a dome-and-spike morphology—is an ECG sign associated with various acute thoracic pathologies, including pneumothorax, and often carries a poor prognosis [82]. Furthermore, iatrogenic complications can blur the diagnosis; for instance, a chest tube inserted for pneumothorax can cause an iatrogenic STEMI by directly compressing the left anterior descending (LAD) coronary artery [41]C. Additionally, the physical stress of a pneumothorax (or the procedure that caused it, such as ) can trigger Takotsubo cardiomyopathy, presenting with substernal chest pain and ST-elevations [91]C.
Infectious and Inflammatory Etiologies
- : Spontaneous pneumothorax is a recognized complication of COVID-19 pneumonia, occurring even in patients who are not receiving mechanical ventilation [81]C[96]C. It typically occurs in the third week of the disease due to diffuse alveolar injury and rupture [98]C.
- Septic Pulmonary Embolism (SPE): Often associated with central venous port infections, SPE can lead to cavitary lesions that rupture into the pleural space, causing bilateral pneumothoraces [93]C.
Special Clinical Syndromes
- Syndrome]] (TES): In reproductive-age individuals, recurrent pneumothorax occurring in sync with the menstrual cycle (catamenial pneumothorax) suggests TES [77]D. MRI using dedicated protocols is often superior to CT for identifying diaphragmatic or pleural endometrial deposits [77]D.
- Vaping-Associated Spontaneous Pneumothorax (VASP): A new diagnostic entity seen in adolescents and young adults using nicotine or cannabis concentrate vape devices [83]C.
- (MPM): While typically presenting with effusion, certain subtypes of MPM can present as recurrent pneumothorax without obvious pleural thickening on initial CT [95]C.
Diagnostic Algorithm for Differentiation
Step 1: Clinical Assessment. Evaluate for tracheal deviation, hemodynamic instability, and history (e.g., vaping, menses, trauma). Step 2: Primary Imaging. Perform chest radiography or lung ultrasound. Look for the visceral pleural line and the presence/absence of lung sliding [76][78]D. Step 3: Advanced Imaging. If the diagnosis is unclear or a mimic (e.g., giant bulla, DH) is suspected, obtain a Chest CT [85]C. Step 4: Specialized Testing. Use MRI for suspected catamenial pneumothorax [77]D or ventilation SPECT/CT to identify persistent air leaks in complex cases [84]C.
| Condition | Key Distinguishing Feature | Preferred Imaging | Clinical Context |
|---|---|---|---|
| Pneumothorax | Visceral pleural line; absence of lung markings peripheral to line [78]D | Chest X-ray / US | Sudden onset chest pain; trauma; tall thin males |
| Giant Bulla | Concave inner border; presence of thin internal septa [85]C | Chest CT | Chronic COPD; smoking history |
| Diaphragmatic Hernia | Presence of bowel gas patterns or stomach bubble in thorax [92]C | Chest CT | History of trauma or congenital defect |
| Cystic Lung Disease | Multiple small cysts (LCH, LAM) rather than a single air space [79]C[90]C | HRCT Chest | Systemic symptoms; specific demographics |
| COVID-19 Pneumonia | Ground-glass opacities associated with air leak [94]C | Chest CT | Fever; cough; positive SARS-CoV-2 test |
Supportive Care and Complication Management
- ▸Persistent air leak (PAL) is defined as a leak lasting >5–7 days and often requires surgical or endoscopic intervention.
- ▸Re-expansion pulmonary edema (RPE) is a rare but potentially fatal complication occurring shortly after drainage of a long-standing pneumothorax.
- ▸Autologous blood patch (ABP) and endobronchial valves (EBV) are effective non-surgical options for managing complex air leaks.
The of pneumothorax extends beyond initial decompression to include the mitigation of procedural complications, pain control, and the resolution of persistent air leaks. Effective supportive care requires a balance between promoting lung re-expansion and avoiding the physiological stressors of rapid pleural pressure changes [103][122]C.
Step 1: Initial Assessment and Severity Classification
Upon stabilization, clinicians must classify the pneumothorax to determine the appropriate level of care. Patients with primary spontaneous pneumothorax (PSP) who are minimally symptomatic may be managed conservatively [113]D. However, those requiring intervention must be monitored for complications such as , re-expansion pulmonary edema (RPE), and persistent air leak (PAL) [108]D[128]C.
- Disposition: Patients with secondary spontaneous pneumothorax (SSP) or those requiring suction should be admitted to a ward or ICU [114]D[118]D.
- Monitoring: Continuous and serial chest X-rays are essential to confirm lung re-expansion and detect early signs of RPE [122]C[128]C.
Step 2: Pain Management and Respiratory Rehabilitation
Chest tube placement is associated with significant morbidity and pain, particularly in younger patients [105]. Effective is critical to facilitate deep breathing and prevent secondary pneumonia.
- Analgesia: Use a multimodal approach including NSAIDs and opioids. Early removal of the chest tube (if clinically indicated) is the most effective way to reduce post-procedural pain [105].
- Respiratory Training: Implement Respiratory Training-Based Rehabilitation (RTBR). This includes targeted breathing exercises combined with standard postoperative care, which has been shown to improve forced expiratory volume in 1 second (FEV1) and reduce hospitalization duration [115].
Step 3: Management of Persistent Air Leak (PAL)
PAL is defined as an air leak lasting more than 5–7 days [106][114]D. In pediatric populations, some define PAL as a leak persisting beyond 48 hours [118]D.
- Low-Pressure Suction: Apply negative pleural suction at -20 cmH2O [103]. This promotes apposition of the visceral and parietal pleura, though its routine use is debated [101][103].
- Evaluation for Surgery: If the leak persists beyond 5–7 days, surgical intervention (e.g., VATS bullectomy and pleurodesis) is the gold standard [114]D[117]D.
- Non-Surgical Candidates: For patients unfit for surgery, consider autologous blood patch or endobronchial valves [104][121]C.
Step 4: Advanced Interventions for PAL
When standard drainage fails, advanced bedside or endoscopic procedures are indicated.
- Autologous Blood Patch (ABP): Instill 50–100 mL of the patient's own blood through the chest tube [125]C. This creates a fibrin clot that seals the leak. Success rates are approximately 71.7%, with many leaks resolving within 24 hours [125]C.
- Endobronchial Valves (EBV): One-way valves are placed via bronchoscopy to occlude the airway leading to the leak [104][123]C. This is particularly effective in patients with severe underlying lung disease, such as or , who cannot tolerate surgery [110]C[127]C.
Step 5: Resolution Criteria and Transition
Criteria for chest tube removal include the absence of an air leak (confirmed by the absence of bubbling in the water seal) and complete lung re-expansion on chest X-ray [105][112]D.
- Trial of Water Seal: Transition from suction to water seal for 4–24 hours.
- Clamping (Optional): Some clinicians clamp the tube for 4 hours before removal to ensure no occult leak exists, though this is not universally required [112]D.
- Removal: Remove the tube during expiration or a Valsalva maneuver to prevent air re-entry [112]D.
Treatment Failure Protocol
If first-line drainage and suction fail to expand the lung or stop the leak within 7 days:
- CT Imaging: Obtain a high-resolution CT to identify the site of the leak or underlying bullous disease [113]D.
- Surgical Consultation: Evaluate for VATS or open thoracotomy [101][117]D.
- Endoscopic Salvage: If surgery is contraindicated, proceed to EBV placement or chemical pleurodesis [104][129]C.
What NOT to Do
- Do NOT apply high-volume negative suction immediately to a lung that has been collapsed for >72 hours; this significantly increases the risk of re-expansion pulmonary edema [122]C[128]C.
- Do NOT rely solely on simple aspiration for SSP; these patients have a high failure rate and usually require formal tube thoracostomy [113]D[114]D.
- Do NOT delay surgical consultation in patients with PAL and known bullous disease, as conservative management is unlikely to succeed [114]D.
| Intervention | Mechanism | Success Rate | Key Consideration | Evidence Level |
|---|---|---|---|---|
| VATS Bullectomy | Surgical resection of blebs | High (>90%) | Gold standard for fit patients | 1c [101][117]D |
| Autologous Blood Patch | Fibrin seal from 50-100mL blood | ~71.7% | Low cost; risk of empyema | 2a [106][125]C |
| Endobronchial Valves | One-way airflow occlusion | Variable | Best for non-surgical candidates | 2a [104][110]C |
| Chemical Pleurodesis | Pleural inflammation/adhesion | Moderate | Can be painful; requires lung expansion | 5 [113]D[129]C |
Landmark Trials and Key Evidence
- ▸Simple aspiration for complete PSP is better tolerated than chest tube drainage but failed to meet noninferiority for 24-hour lung expansion in the Marx et al. trial [138].
- ▸Conservative management of blunt traumatic pneumothorax is safe in hemodynamically stable patients, potentially avoiding the morbidity of tube thoracostomy [147].
- ▸Digital drainage settings of -8 cm H2O are non-inferior to -15 cm H2O for managing postoperative air leaks, supporting a more physiologic approach to suction [9].
The of has evolved from a paradigm of mandatory invasive intervention to a more nuanced, evidence-based approach that prioritizes patient comfort, ambulatory care, and the avoidance of unnecessary procedures. Modern clinical practice is heavily influenced by randomized controlled trials (RCTs) evaluating the efficacy of simple aspiration versus tube thoracostomy, the safety of conservative management in trauma, and the optimization of digital drainage systems for postoperative air leaks.
Primary Spontaneous Pneumothorax (PSP): Aspiration vs. Drainage
The debate between simple aspiration and intercostal drainage for the first episode of complete PSP was addressed in a major prospective, open-label, randomized noninferiority trial by Marx et al. (2023) [138].
- Trial Design: RCT involving 402 adults (18–50 years) with complete PSP across 31 hospitals [138].
- Intervention: Simple aspiration (n=200) vs. chest tube drainage (n=202) [138].
- Primary Outcome: Pulmonary expansion at 24 hours [138].
- Key Results: Lung expansion was achieved in 79.4% of the aspiration group compared to 85.1% in the drainage group. The study failed to demonstrate the noninferiority of simple aspiration for immediate expansion [138]. However, aspiration was associated with significantly better tolerance and fewer adverse events [138].
- Clinical Impact: While chest tube drainage remains the standard for ensuring immediate expansion in complete PSP, simple aspiration is a viable first-line option for patients where avoiding hospitalization and procedural morbidity is a priority [138].
Further evidence from the Randomised Ambulatory Management of Primary Pneumothorax (RAMPP) trial highlights the economic trade-offs of ambulatory care. Ambulatory management significantly reduces initial hospitalization duration but is associated with a higher rate of adverse events, leading to a complex cost-effectiveness profile where ambulatory care may not always be the dominant strategy [139]. Predictive modeling suggests that patients with longer symptom duration and higher baseline symptom scores are more likely to fail medical management and require surgical intervention [10].
Traumatic Pneumothorax: Conservative vs. Invasive Management
In the context of blunt thoracic trauma, the necessity of for all patients is being challenged by emerging evidence supporting conservative management for stable patients [147].
- Evidence Synthesis: A 2025 meta-analysis by Harrison analyzed current evidence for blunt traumatic pneumothorax, concluding that clinicians can safely omit tube thoracostomy in hemodynamically stable patients without significant respiratory distress [147].
- Ongoing Research: The CoMiTED trial is currently evaluating the clinical and cost-effectiveness of initial conservative management versus immediate chest drain insertion for "significant" traumatic pneumothoraces, aiming to reduce avoidable pain and complications [149].
For patients requiring drainage, the use of negative pleural suction remains controversial. An RCT by Arora et al. (2025) compared slow negative suction to conventional water seal drainage in 100 trauma patients, finding that suction may influence the rate of lung re-expansion and duration of drainage [132]. Similarly, Priyadarshi et al. (2024) demonstrated that low-pressure negative suction can shorten the duration of intercostal drainage in trauma patients [103].
Postoperative Air Leak and Drainage Optimization
Management of air leaks following pulmonary resection has been refined through trials focusing on digital drainage settings and pleurodesis techniques.
- Digital Drainage Pressures: The Takamochi et al. (2026) multicenter RCT randomized 2379 patients to either -8 cm H2O or -15 cm H2O intrathoracic pressure [9]. The study found no significant difference in the incidence of prolonged air leak (67.7% vs 60.4%, p=0.303), suggesting that lower suction pressures are physiologically sufficient and do not worsen outcomes [9].
- Suction Strategies: Maxwell et al. (2025) compared standard suction (-20 cm H2O) to low suction (-8 cm H2O) using digital systems. They found that low suction did not significantly shorten the duration of air leaks but confirmed the safety of using a single 24 Fr Blake drain for most minimally invasive resections [14].
- Pleurodesis for Air Leaks: For persistent postoperative leaks, Skrzypczak et al. (2025) compared intrapleural 40% glucose solution to autologous blood patch pleurodesis [8]. Glucose solution emerged as a novel, potentially effective alternative for inducing pleurodesis and sealing leaks [8].
Procedural Safety and Prevention
Landmark evidence has also established protocols to reduce iatrogenic pneumothorax during common procedures.
- Ultrasound Guidance: The ZEROFLUOROAXI trial (2024) demonstrated that ultrasound-guided axillary vein access for cardiac lead implantation significantly reduces the risk of accidental pleura puncture and subsequent pneumothorax compared to traditional fluoroscopic techniques [136]. Similarly, modified ultrasound-guided subclavian puncture has shown higher one-time success rates and lower complication rates than blind techniques [144].
- Biopsy Techniques: In CT-guided lung biopsies, track sealing with gelatin sponge slurry (GSS) was found to be superior to saline in reducing the rate of post-biopsy pneumothorax [141]. For peripheral lung lesions, Cryo-Radial biopsy (combining radial-endobronchial ultrasound with cryoprobe) offers a diagnostic yield comparable to CT-guided transthoracic biopsy but with a significantly higher safety profile and lower pneumothorax risk [146].
| Trial | Year | N | Intervention | Key Finding |
|---|---|---|---|---|
| Marx et al. [138] | 2023 | 402 | Aspiration vs. Chest Tube | Aspiration better tolerated; drainage superior for 24h expansion. |
| Takamochi et al. [9] | 2026 | 2379 | -8 vs. -15 cm H2O Suction | No difference in prolonged air leak incidence between pressures. |
| Harrison Meta-analysis [147] | 2025 | N/A | Conservative vs. Drainage | Conservative management safe for stable blunt trauma patients. |
| ZEROFLUOROAXI [136] | 2024 | RCT | US-guided vs. Fluoroscopy | Ultrasound significantly reduces iatrogenic pneumothorax risk. |
| Skrzypczak et al. [8] | 2025 | RCT | 40% Glucose vs. Blood Patch | Glucose solution is a viable agent for postoperative air leak pleurodesis. |
Guidelines and Resources
- ▸Size definitions for intervention vary significantly, with the BTS/French guidelines using a **2 cm** hilar threshold and the ACCP using a **3 cm** apical threshold.
- ▸The 2024 ERS/EACTS/ESTS guidelines represent the most current multidisciplinary consensus, prioritizing clinical stability over radiographic size.
- ▸Specialized protocols exist for high-risk groups, including patients with [[cystic fibrosis]], pregnant women, and those planning air travel.
The of spontaneous pneumothorax (SP) has historically been characterized by significant heterogeneity in clinical practice, driven by conflicting recommendations from major international societies [101][168]D. Recent efforts, most notably the 2024 joint guidelines from the European Respiratory Society (ERS), European Association for Cardio-Thoracic Surgery (EACTS), and European Society of Thoracic Surgeons (ESTS), have sought to provide a multidisciplinary, evidence-based framework to standardize care [101][102]. These guidelines emphasize the importance of clinical stability over radiographic size alone and advocate for a more conservative approach in selected patients [101].
Major International Guidelines and Discrepancies
A primary point of contention among guidelines is the definition of pneumothorax size, which directly influences the threshold for intervention. The British Thoracic Society (BTS) and the French Speaking Society of Respiratory Diseases (SPLF) define a "large" primary spontaneous pneumothorax (PSP) as a visible rim of air ≥2 cm at the level of the hilum [51][174]D. In contrast, the American College of Chest Physicians (ACCP) uses a threshold of ≥3 cm measured at the apex [170]D[174]D. Evidence suggests that hilar measurements are more accurate predictors of the need for intercostal chest drain insertion than apical distances [174]D.
Furthermore, the role of simple aspiration remains debated. While the BTS recommends needle aspiration (using a 16–18G cannula) as first-line therapy for all PSPs requiring intervention, the ACCP consensus statement suggests it has a limited role [167]C[168]D. Aspiration is preferred by some because it reduces hospital stay and procedure-related pain compared to traditional tube [167]C.
Protocol for Radiographic Size Assessment
To ensure consistency with modern guidelines, clinicians should follow a standardized measurement protocol [51][170]D:
- Step 1: Obtain a standard upright posteroanterior (PA) chest radiograph.
- Step 2: Identify the visceral pleural line (lung margin).
- Step 3: Measure the interpleural distance at the level of the hilum (BTS/French criteria) or the apex (ACCP criteria).
- Step 4: Categorize as "Large" if the distance is ≥2 cm (BTS/French) or ≥3 cm (ACCP) [51][170]D.
Specialized Population Guidelines
Cystic Fibrosis (CF)
The CF Foundation recommends aggressive management for pneumothorax in patients with due to their reduced physiological reserve and the high risk of recurrence [153]. Unlike PSP, even small pneumothoraces in CF may require intervention if the patient is symptomatic [153].
Pregnancy
Spontaneous pneumothorax in pregnancy is rare, typically occurring at a mean gestational age of 25 weeks [160]. Guidelines emphasize a multidisciplinary approach to balance maternal stability with fetal safety, often favoring conservative management or simple aspiration for stable patients to avoid the risks of general anesthesia [160].
Neonatology
For neonatal pneumothorax, lung is increasingly recommended as a fast, radiation-free diagnostic tool [164]. Clinicians are trained to identify specific artifacts, such as the "lung point," which has high specificity for rule-in diagnosis [164].
Air Travel
The BTS provides specific recommendations for patients planning air travel. At cabin altitudes of 8000 feet, the hypobaric environment (0.75 atmospheres) causes trapped gas to expand [165]. Patients should generally wait until a pneumothorax is fully resolved (confirmed by radiography) before flying [165].
Procedural Safety and Iatrogenic Risk
Guidelines for central venous catheterization (CVC) emphasize the use of real-time ultrasound guidance to mitigate the risk of iatrogenic pneumothorax [157][172]D. Similarly, in the management of advanced emphysema with one-way valves, clinicians must be prepared for pneumothorax, which occurs in up to 34% of treated patients [158]. Timely resolution is essential to ensure the patient still achieves the clinical benefits of lung volume reduction [158].
Clinical Prediction Tools and Calculators
- Collins' Method: A volumetrically-derived formula used to calculate the percentage of pneumothorax based on interpleural distances measured at the apex, mid-thorax, and base [170]D.
- BTS Air Travel Assessment: A primary care tool used to identify high-risk patients who may require in-flight supplemental oxygen or pre-flight clearance [165].
| Guideline | Organization | Year | Key Recommendations |
|---|---|---|---|
| Joint ERS/EACTS/ESTS | ERS, EACTS, ESTS | 2024 | Multidisciplinary approach; emphasizes clinical stability and evidence-based management [101]. |
| French PSP Guidelines | SPLF, SFMU, SRLF | 2023 | Defines "large" PSP as ≥2 cm at the hilum; supports standardized expert consensus [51]. |
| German S3 Guideline | DGT, DGP, DRG | 2019 | Comprehensive management of spontaneous and post-interventional pneumothorax [159]. |
| SECT Guideline | Spanish Society of Thoracic Surgery | 2018 | GRADE-based recommendations for surgical and medical management [163]. |
| BTS Air Travel | British Thoracic Society | 2011 | Guidance on hypobaric risks and pre-flight clearance for respiratory patients [165]. |
| CF Pulmonary | CF Foundation | 2010 | Aggressive management of pneumothorax in due to high morbidity [153]. |
| ACCP Consensus | American College of Chest Physicians | 2001 | Uses apical measurement for size; recommends early surgery for secondary pneumothorax [168]D[170]D. |
References
- [1]
Robbins MS, Kuruvilla D, Blumenfeld A et al.. “Trigger point injections for headache disorders: expert consensus methodology and narrative review.” Headache (2014). PMID: 25168295 ↗
L5REVIEW_NARRATIVECited in: Definition, Synonyms, and Classification - [2]
Donn SM. “Neonatal ventilators: how do they differ?” Journal of perinatology : official journal of the California Perinatal Association (2009). PMID: 19399015 ↗
L5REVIEW_NARRATIVECited in: Definition, Synonyms, and Classification - [3]
Wei MH, Blake PW, Shevchenko J et al.. “The folliculin mutation database: an online database of mutations associated with Birt-Hogg-Dubé syndrome.” Human mutation (2009). PMID: 19562744 ↗
L5OTHERCited in: Definition, Synonyms, and Classification - [4]
Welch BT, Eiken PW, Atwell TD et al.. “A Single-Institution Experience in Percutaneous Image-Guided Biopsy of Malignant Pleural Mesothelioma.” Cardiovascular and interventional radiology (2017). PMID: 28138725 ↗
L5OTHERCited in: Definition, Synonyms, and Classification - [5]
Thompson P, Johannigman J, Hudson AJ et al.. “Traumatic Tension Pneumothorax: A Tale of Two Pathologies.” Journal of special operations medicine : a peer reviewed journal for SOF medical professionals (2025). PMID: 39688900 ↗
L5OTHERCited in: Definition, Synonyms, and Classification - [6]
Sedlák V, Koblížek V, Šimek R. “[Ultrasound examination of the chest in the hands of the clinical physician].” Vnitrni lekarstvi (2018). PMID: 29303294 ↗
L5OTHERCited in: Definition, Synonyms, and Classification - [7]
Zhang Y, Wang Y, Wang J et al.. “The prevalence of spontaneous pneumothorax in patients with BHD syndrome: a systematic review and meta-analysis.” Orphanet journal of rare diseases (2025). PMID: 40336059 ↗
L2aSR_OBSCited in: Epidemiology and Risk Factors - [8]
Skrzypczak PJ, Dobiecki T, Rozmiarek M et al.. “Comparison of 40% Glucose Solution and Autologous Blood Patch Pleurodesis for the Treatment of Postoperative Air Leak After Lung Resections: A Prospective Randomized Controlled Study.” European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery (2025). PMID: 41191623 ↗
L1bRCTCited in: Epidemiology and Risk Factors, Landmark Trials and Key Evidence - [9]
Takamochi K, Endo M, Funai K et al.. “Randomized Multicenter Trial of -8 cm H2O vs -15 cm H2O Intrathoracic Pressure Digital Thoracic Drainage for Air Leaks After Anatomic Pulmonary Resection.” The Annals of thoracic surgery (2026). PMID: 40886755 ↗
L1bRCTCited in: Epidemiology and Risk Factors, Landmark Trials and Key Evidence - [10]
Raza MZ, Iqbal B, Sundaralingam A et al.. “Which clinical factors are predictive of outcome in primary spontaneous pneumothorax management?” BMJ open respiratory research (2025). PMID: 40541275 ↗
L1bRCTCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors, Landmark Trials and Key Evidence - [11]
Agamennone M, Lena F, Donati F et al.. “Bilateral Pneumothorax After Minimally Invasive Repair of Pectus Excavatum: Report of a Rare Life-Threatening Complication.” The Thoracic and cardiovascular surgeon (2026). PMID: 40962257 ↗
L2aSR_OBSCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors, History and Physical Examination - [12]
Al-Taj M, Alsabbah A, Ma'ali T et al.. “Vaping-Associated Pneumothorax: A Systematic Review of Case Reports and Case Series.” Medicina (Kaunas, Lithuania) (2025). PMID: 40142348 ↗
L2aSR_OBSCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors - [13]
Macharia-Nimietz EF, Mallaev M, Gecas P et al.. “Efficacy of Non-Powered Stapler in Lung Volume Reduction Surgery of Severe Lung Emphysema: A Prospective Randomized Single-Blinded Monocentric Study.” Interdisciplinary cardiovascular and thoracic surgery (2026). PMID: 41787969 ↗
L1bRCTCited in: Epidemiology and Risk Factors, Landmark Trials and Key Evidence - [14]
Maxwell CM, Weksler B, Shahbahrami K et al.. “Optimal Suction Strategy After Pulmonary Resection Using a Digital Drainage System With a Single Blake Drain: A Randomized Study.” Innovations (Philadelphia, Pa.) (2025). PMID: 40745972 ↗
L1bRCTCited in: Epidemiology and Risk Factors, Landmark Trials and Key Evidence - [15]
Jørgensen KH, Christensen TD, Titlestad IL et al.. “Risk Factors for Pneumothorax After Treatment With Endobronchial Valves: A Cohort Study.” Respirology (Carlton, Vic.) (2025). PMID: 40442057 ↗
L2bCOHORTCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors - [16]
Farronato A, Travaglia C, Ravasin A et al.. “Patients with coronavirus disease 2019 and spontaneous pneumothorax: a propensity-matched, multicentre case-control study.” Interdisciplinary cardiovascular and thoracic surgery (2025). PMID: 40139717 ↗
L3bCASE_CONTROLCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors - [17]
Zhu ZY, Yun YQ, Li H et al.. “Subpleural injection of gelatin sponge particles to reduce pneumothorax incidence in CT-guided lung biopsies: a retrospective single-center case-control study.” BMC cancer (2025). PMID: 40122807 ↗
L3bCASE_CONTROLCited in: Epidemiology and Risk Factors - [18]
Yang J, Mo X, Wu F et al.. “Analysis of the risk factors associated with complications following CT-guided percutaneous core needle biopsy of small pulmonary nodules (≤1.5 cm): A single-center retrospective study.” Medicine (2025). PMID: 41305684 ↗
L2bCOHORTCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors - [19]
Reiber M, Mormol J, Krech L et al.. “Not All Black and White: Is Routine Chest Radiography Following Rib Fractures Beneficial?” The Journal of surgical research (2026). PMID: 41719620 ↗
L5OTHERCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors - [20]
Shacker M, Wang L, Chang L et al.. “Pleural space complications after lung transplantation.” The Journal of thoracic and cardiovascular surgery (2026). PMID: 41338447 ↗
L5OTHERCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors - [21]
Kimachi T, Kowa H. “Pneumothorax During Mechanical Ventilation in Patients With Amyotrophic Lateral Sclerosis: Incidence, Risk Factors, and Impact on Survival.” Muscle & nerve (2026). PMID: 41287942 ↗
L5OTHERCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors, History and Physical Examination - [22]
Goh KJ, Lim MT, Chua BLW et al.. “Incidence and risk factors for re-expansion pulmonary oedema following medical thoracoscopy.” BMJ open respiratory research (2025). PMID: 41253402 ↗
L5OTHERCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors - [23]
Adachi T, Omasa M, Takehara R et al.. “The Safety and Efficacy of Secondary Spontaneous Pneumothorax Surgery: Especially in Interstitial Lung Disease and Chronic Obstructive Pulmonary Disease.” European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery (2025). PMID: 41237316 ↗
L5OTHERCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors - [24]
Aydin S, Aydin SK, Gursoy D et al.. “Factors Associated With Early Recurrence in Non-Surgically Managed Primary Spontaneous Pneumothorax.” World journal of surgery (2025). PMID: 40689755 ↗
L5OTHERCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors - [25]
Zhao XH, Zhu SB, Li X et al.. “CT-Guided Lung Biopsy with Needle Embolization Using Gelatin Sponge Slurry to Prevent Pneumothorax and Pulmonary Hemorrhage: A Propensity Score Matching Controlled Study.” Academic radiology (2025). PMID: 40368714 ↗
L5OTHERCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors - [26]
Dufraigne A, Bonjean P, Gergele L et al.. “Noninvasive ventilation in chest trauma-related acute respiratory failure related to chest trauma: Efficacy and risk of pneumothorax.” European journal of trauma and emergency surgery : official publication of the European Trauma Society (2025). PMID: 40366384 ↗
L5OTHERCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors - [27]
Liu YW, Kao CN, Ho CC et al.. “Effect of environmental factors on postoperative recurrent primary spontaneous pneumothorax: a case-crossover study.” Respiratory research (2025). PMID: 40346647 ↗
L5OTHERCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors - [28]
Mahajan AK, Collar N, Muldowney F et al.. “Incidence and outcomes for post-bronchoscopic lung volume reduction (BLVR) pneumothoraces stratified by target lobe treated.” Respiratory medicine (2025). PMID: 40339665 ↗
L5OTHERCited in: Epidemiology and Risk Factors - [29]
Murgu S, Chen AC, Gilbert CR et al.. “A Prospective, Multicenter Evaluation of Safety and Diagnostic Outcomes With Robotic-Assisted Bronchoscopy: Results of the Transbronchial Biopsy Assisted by Robot Guidance in the Evaluation of Tumors of the Lung (TARGET) Trial.” Chest (2025). PMID: 40300665 ↗
L5OTHERCited in: Epidemiology and Risk Factors, Guidelines and Resources - [30]
Ha X, Feng Z, Wu Y et al.. “Management for perioperative complications of diaphragmatic surgery in ovarian cancer at a Chinese tertiary cancer center.” Journal of gynecologic oncology (2025). PMID: 40275686 ↗
L5OTHERCited in: Epidemiology and Risk Factors - [31]
Brönnimann MP, Barroso MC, Manser L et al.. “The role of gravitational effects and pre-puncture techniques in reducing pneumothorax during CT-guided lung biopsies.” La Radiologia medica (2025). PMID: 40232655 ↗
L5OTHERCited in: Epidemiology and Risk Factors - [32]
Beiriger J, Molin N, Robinson J et al.. “The Need for Postoperative Chest X-Ray After Placement of Hypoglossal Nerve Stimulator.” The Laryngoscope (2025). PMID: 40059803 ↗
L5OTHERCited in: Epidemiology and Risk Factors - [33]
Calandri M, Brino J, Yevich S et al.. “Multicenter external validation of a novel aggregated technique for percutaneous CT guided lung biopsy for multiple samplings: the ExtraPEARL study.” European radiology (2025). PMID: 40055230 ↗
L5OTHERCited in: Epidemiology and Risk Factors - [34]
Nishikimi K, Tate S, Matsuoka A et al.. “Intra- and postoperative complications associated with diaphragmatic surgery for advanced ovarian cancer.” Journal of gynecologic oncology (2025). PMID: 40017162 ↗
L5OTHERCited in: Epidemiology and Risk Factors - [35]
Wang R, Chen X, Xu S et al.. “Prevalence and recurrence rates of spontaneous pneumothorax in patients with diffuse cystic lung diseases in China.” Orphanet journal of rare diseases (2025). PMID: 39934870 ↗
L5OTHERCited in: Epidemiology and Risk Factors - [36]
Sun M, Jiang H, Zhao L et al.. “Association between Pneumothorax and Neonatal Outcomes among Very Preterm Infants: A Multicenter Cohort Study.” Neonatology (2025). PMID: 40383120 ↗
L2bCOHORTCited in: Epidemiology and Risk Factors, Etiology and Triggering Factors - [37]
Ahmad SJS, Degiannis JR, Head M et al.. “Meta-analysis of the optimal needle length and decompression site for tension pneumothorax and consensus recommendations on current ATLS and ETC guidelines.” World journal of emergency surgery : WJES (2025). PMID: 40383767 ↗
L2aSR_OBSCited in: Etiology and Triggering Factors - [38]
Chen X, Ryu JH, Hu X. “Spontaneous pneumothorax-associated with genetic disorders.” Therapeutic advances in respiratory disease (2026). PMID: 41905781 ↗
L5REVIEW_NARRATIVECited in: Etiology and Triggering Factors - [39]
Zhou SQ, Luo F, Ran X et al.. “Nonlinear association between lung needle path CT attenuation values and postprocedural immediate pneumothorax following computed tomography-guided lung biopsy: a retrospective cohort study.” BMC pulmonary medicine (2024). PMID: 39543604 ↗
L2bCOHORTCited in: Etiology and Triggering Factors - [40]
Wang M, Jiao J, Liu J et al.. “Radiological features of paraquat-induced pulmonary fibrosis.” Clinical toxicology (Philadelphia, Pa.) (2025). PMID: 40874874 ↗
L4CASE_REPORTCited in: Etiology and Triggering Factors - [41]
Holtmann JA, Kipfer B, Lehmann B et al.. “Iatrogenic STEMI in a male trauma patient due to coronary artery compression by a left sided chest tube.” The American journal of emergency medicine (2025). PMID: 39909802 ↗
L4CASE_REPORTCited in: Etiology and Triggering Factors, Differential Diagnosis - [42]
Latifi A, Wang D, Backer ED et al.. “Pleural Manometry in Pneumothorax: Evaluating Tension Physiology and Predicting Outcomes.” Chest (2026). PMID: 41076067 ↗
L5OTHERCited in: Etiology and Triggering Factors - [43]
Xie L, Song L, Wang J et al.. “Think twice before diagnosing tension pneumothorax: a retrospective analysis of pseudotension pneumothorax.” European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery (2025). PMID: 40128160 ↗
L5OTHERCited in: Etiology and Triggering Factors, Differential Diagnosis - [44]
Brock JM, Dittrich SA, Eichhorn F et al.. “Lessons Learned: Risk Factors and Clinical Impact of Severe Pneumothorax After Endoscopic Lung Volume Reduction With Endobronchial Valves.” Chest (2025). PMID: 39521377 ↗
L5OTHERCited in: Etiology and Triggering Factors - [45]
Turan YB. “Risk factors affecting the development of pneumothorax in patients followed up in intensive care with a diagnosis of COVID-19.” BMC infectious diseases (2024). PMID: 39501177 ↗
L5OTHERCited in: Etiology and Triggering Factors - [46]
Bénard-Laribière A, Pambrun E, Kouzan S et al.. “Association of fluoroquinolones with the risk of spontaneous pneumothorax: nationwide case-time-control study.” Thorax (2025). PMID: 39393909 ↗
L5OTHERCited in: Etiology and Triggering Factors - [47]
Pulle MV, Puri HV, Kumar A. “Reframing spontaneous pneumothorax: A practical guide to the PLEX variant classification.” Asian cardiovascular & thoracic annals (2026). PMID: 41499289 ↗
L5REVIEW_NARRATIVECited in: Etiology and Triggering Factors - [48]
Griffiths E. “Helicopter emergency medical services use of thoracic point of care ultrasound for pneumothorax: a systematic review and meta-analysis.” Scandinavian journal of trauma, resuscitation and emergency medicine (2021). PMID: 34801070 ↗
L2aSR_OBSCited in: History and Physical Examination - [49]
Schubert AK, Dinges HC, Wulf H et al.. “Interscalene versus supraclavicular plexus block for the prevention of postoperative pain after shoulder surgery: A systematic review and meta-analysis.” European journal of anaesthesiology (2019). PMID: 31045699 ↗
L2aSR_OBSCited in: History and Physical Examination - [50]
Kim S, Bae CM, Do YW et al.. “Serratus Anterior Plane Block and Intercostal Nerve Block after Thoracoscopic Surgery.” The Thoracic and cardiovascular surgeon (2021). PMID: 32222960 ↗
L1bRCTCited in: History and Physical Examination - [51]
Jouneau S, Ricard JD, Seguin-Givelet A et al.. “SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV).” Respiratory medicine and research (2023). PMID: 37003203 ↗
L1cGUIDELINECited in: History and Physical Examination, Landmark Trials and Key Evidence, Guidelines and Resources - [52]
Dridi D, Ottolini FL, Ambruoso D et al.. “Clinical features and management of thoracic endometriosis: a 20-year monocentric retrospective study.” Archives of gynecology and obstetrics (2025). PMID: 40158040 ↗
L2bCOHORTCited in: History and Physical Examination - [53]
Park JS, Do YW, Park JM et al.. “Under-recognized primary spontaneous pneumothorax in ALS: a multicenter retrospective study.” Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology (2019). PMID: 31267304 ↗
L2bCOHORTCited in: History and Physical Examination - [54]
Miró Ò, Llorens P, Jiménez S et al.. “Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019: A Case-Control, Emergency Medicine-Based Multicenter Study.” Chest (2021). PMID: 33227276 ↗
L3bCASE_CONTROLCited in: History and Physical Examination - [55]
Lin YJ, Chen GX, Zhang Y. “Postoperative management of spontaneous pneumothorax in arthroscopic shoulder superior capsular reconstruction: A case report and review of literature.” Chinese journal of traumatology = Zhonghua chuang shang za zhi (2022). PMID: 35440401 ↗
L4CASE_REPORTCited in: History and Physical Examination - [56]
Chuah JS, Raymond Lim ZM, Lee EP et al.. “Emergency repair of blunt traumatic bronchus injury presenting with massive air leak.” Chinese journal of traumatology = Zhonghua chuang shang za zhi (2022). PMID: 35031204 ↗
L4CASE_REPORTCited in: History and Physical Examination - [57]
Delhez Q, Bairy L, Mitchell J et al.. “Major pneumothorax during pediatric cardiac MRI procedure under general anesthesia: step-by-step analysis and importance of a well-known environment and material.” BMC anesthesiology (2024). PMID: 38166574 ↗
L4CASE_REPORTCited in: History and Physical Examination - [58]
González-Pacheco H, Gopar-Nieto R, Jiménez-Rodríguez GM et al.. “Bilateral spontaneous pneumothorax in SARS-CoV-2 infection: A very rare, life-threatening complication.” The American journal of emergency medicine (2021). PMID: 32712235 ↗
L4CASE_REPORTCited in: History and Physical Examination - [59]
Spiro JE, Sisovic S, Ockert B et al.. “Secondary tension pneumothorax in a COVID-19 pneumonia patient: a case report.” Infection (2020). PMID: 32557347 ↗
L4CASE_REPORTCited in: History and Physical Examination - [60]
Ghisalberti M, Guerrera F, De Vico A et al.. “Age and Clinical Presentation for Primary Spontaneous Pneumothorax.” Heart, lung & circulation (2020). PMID: 32718900 ↗
L5REVIEW_NARRATIVECited in: History and Physical Examination - [61]
Srinivas S, Lutz C, Rachwal B et al.. “Management Patterns and Outcomes of Children With Traumatic Occult Pneumothorax.” The Journal of surgical research (2026). PMID: 41832880 ↗
L5OTHERCited in: History and Physical Examination - [62]
Occelli C, Lenoir M, Naudet Lasserre A et al.. “Prehospital diagnostic performance of emergency physicians in identifying blunt traumatic pneumothorax requiring early decompression.” BMC emergency medicine (2026). PMID: 41530696 ↗
L5OTHERCited in: History and Physical Examination - [63]
Greene AC, Schaefer EW, Ziegler O et al.. “Surgical management patterns for spontaneous pneumothorax in adolescents and young adults.” Surgery (2025). PMID: 40907218 ↗
L5OTHERCited in: History and Physical Examination - [64]
Benhaïm E, Roth B, Michel F et al.. “Management of primary spontaneous pneumothorax in teenagers: An 11-year study.” Acta paediatrica (Oslo, Norway : 1992) (2022). PMID: 34923666 ↗
L5OTHERCited in: History and Physical Examination - [65]
Nutbeam T, Fenwick R, Smith J et al.. “A comparison of the demographics, injury patterns and outcome data for patients injured in motor vehicle collisions who are trapped compared to those patients who are not trapped.” Scandinavian journal of trauma, resuscitation and emergency medicine (2021). PMID: 33446210 ↗
L5OTHERCited in: History and Physical Examination - [66]
Jeon HW, Kim YD, Sim SB. “Should We Consider the Resected Lung Volume in Primary Spontaneous Pneumothorax?” World journal of surgery (2020). PMID: 32328783 ↗
L5OTHERCited in: History and Physical Examination - [67]
Huang HK, Huang YJ, Lin KH et al.. “Severity of Pectus Excavatum is a Risk Factor for Primary Spontaneous Pneumothorax.” World journal of surgery (2020). PMID: 32040606 ↗
L5OTHERCited in: History and Physical Examination - [68]
Ziegler B, Kenngott T, Fischer S et al.. “Early hypothermia as risk factor in severely burned patients: A retrospective outcome study.” Burns : journal of the International Society for Burn Injuries (2019). PMID: 31378620 ↗
L5OTHERCited in: History and Physical Examination - [69]
Allain PA, Carella M, Agrafiotis AC et al.. “Comparison of several methods for pain management after video-assisted thoracic surgery for pneumothorax: an observational study.” BMC anesthesiology (2019). PMID: 31279330 ↗
L5OTHERCited in: History and Physical Examination - [70]
Li Y, He K, Wu J et al.. “Delayed tension pneumothorax 2 days after shoulder arthroscopic rotator cuff repair: a case report.” BMC musculoskeletal disorders (2025). PMID: 40275225 ↗
L4CASE_REPORTCited in: History and Physical Examination - [71]
Ki S, Choi B, Cho SB et al.. “Unexpected Tension Pneumothorax Developed during Anesthetic Induction Aggravated by Positive Pressure Ventilation: A Case Report.” Medicina (Kaunas, Lithuania) (2023). PMID: 37763751 ↗
L4CASE_REPORTCited in: History and Physical Examination - [72]
Kikutani K, Ohshimo S, Sadamori T et al.. “Regional respiratory sound abnormalities in pneumothorax and pleural effusion detected via respiratory sound visualization and quantification: case report.” Journal of clinical monitoring and computing (2022). PMID: 35147849 ↗
L4CASE_REPORTCited in: History and Physical Examination - [73]
Yamamoto H, Satomi K, Aizawa Y. “Electrocardiographic manifestations in a large right-sided pneumothorax.” BMC pulmonary medicine (2021). PMID: 33757495 ↗
L4CASE_REPORTCited in: History and Physical Examination - [74]
Ashcroft J, Murphy S, Laing TA et al.. “A new clinical presentation: breast implant pneumocapsule and pneumothorax following penetrating chest wall trauma.” Annals of the Royal College of Surgeons of England (2021). PMID: 33645284 ↗
L4CASE_REPORTCited in: History and Physical Examination - [75]
Goldman RD. “Spontaneous pneumothorax in children.” Canadian family physician Medecin de famille canadien (2020). PMID: 33077450 ↗
L4CASE_REPORTCited in: History and Physical Examination - [76]
El Husseini K, Flament T, Laroumagne S et al.. “Mapping Bullous Emphysema With Lung Ultrasound: A Prospective Multicentre Study.” Respirology (Carlton, Vic.) (2025). PMID: 40059443 ↗
L2bTRIAL_NONRANDOMCited in: Differential Diagnosis, Landmark Trials and Key Evidence - [77]
Xiao L, White D, Kruger LF et al.. “Thoracic endometriosis syndrome: imaging findings and the value of a dedicated MRI protocol.” Abdominal radiology (New York) (2025). PMID: 39964372 ↗
L5REVIEW_NARRATIVECited in: Differential Diagnosis - [78]
Yamada A, Taiji R, Nishimoto Y et al.. “Pictorial Review of Pleural Disease: Multimodality Imaging and Differential Diagnosis.” Radiographics : a review publication of the Radiological Society of North America, Inc (2024). PMID: 38547031 ↗
L5REVIEW_NARRATIVECited in: Differential Diagnosis - [79]
Carmo LHKD, Jaca LAM, Barreiros LMV et al.. “Challenges and strategies: treating spontaneous pneumothorax in massive pulmonary langerhans cell histiocytosis in children.” Revista paulista de pediatria : orgao oficial da Sociedade de Pediatria de Sao Paulo (2024). PMID: 39630790 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [80]
Skopelidou V, Hurník P, Tulinský L et al.. “A unique case of AH-dominant type nodular pulmonary amyloidosis presenting as a spontaneous pneumothorax: a case report and review of the literature.” Pathology oncology research : POR (2023). PMID: 37808084 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [81]
Alhakeem A, Khan MM, Al Soub H et al.. “Case Report: COVID-19-Associated Bilateral Spontaneous Pneumothorax-A Literature Review.” The American journal of tropical medicine and hygiene (2020). PMID: 32666917 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [82]
Mahmoudi E, Hui JMH, Leung KSK et al.. “Spiked Helmet Electrocardiographic Sign-A Systematic Review of Case Reports.” Current problems in cardiology (2023). PMID: 36493916 ↗
L2aSR_OBSCited in: Differential Diagnosis - [83]
Olgin GK, Ludwig C, Matthay MA et al.. “Pneumothoraces Associated With Vaping Cannabis Concentrate.” Pediatrics (2024). PMID: 39468959 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [84]
Phan T, Ricard C, Lee L et al.. “SPECT/CT with 99mTc-DTPA in a Patient with Persistent Complex Pneumothorax after Endobronchial Valve Placement.” Radiology. Cardiothoracic imaging (2024). PMID: 39115407 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [85]
Ye Y, Zhan Y. “Giant pulmonary bullae mistaken for pneumothorax.” The American journal of emergency medicine (2024). PMID: 39004543 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [86]
Rubin J, Chiu ML, Mino-Kenudson M et al.. “ARDS With Pneumothorax in a Young Adult.” Chest (2022). PMID: 35131063 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [87]
Kumar P, Skrabal J, Frasure SE et al.. “Pacemaker lead related myocardial perforation.” The American journal of emergency medicine (2022). PMID: 34511285 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [88]
Homer KL, Mandziuk J, Hirji A et al.. “Progressive Dyspnea With Recurrent Pneumothoraces.” Chest (2021). PMID: 34366047 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [89]
Hamad AM, Elmahrouk AF, Elmistekawy EM. “Respiratory Distress and Chest Pain in an Airplane Passenger With Radiolucent Left Hemithorax.” Chest (2021). PMID: 33965156 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [90]
Agrawal A, Karle E, Patel TP et al.. “A Pregnant Woman Presenting With Progressively Worsening Dyspnea and Pneumothorax.” Chest (2020). PMID: 32505325 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [91]
Sawan MA, Sayegh MN, Al Turk A et al.. “In-Acupuncture-induced Pneumothorax and Takotsubo Cardiomyopathy.” Interventional cardiology clinics (2026). PMID: 41276393 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [92]
Koh WH, Ko PJ, Su YT et al.. “Unmasking a hidden culprit: late-presenting congenital diaphragmatic hernia beyond infancy: A case report and literature review.” Medicine (2024). PMID: 38518042 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [93]
Ikejiri K, Goto H, Usui M et al.. “Septic pulmonary embolism and subsequent bilateral pneumothorax in patients undergoing chemoradiotherapy for head angiosarcoma: An autopsy case report and literature review.” Medicine (2022). PMID: 36397415 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [94]
Coppola MG, Lugarà M, Tamburrini S et al.. “Pneumomediastinum and Pneumothorax as Relevant Complications of Sub-Intensive Care of Patients with COVID-19: Description of a Case Series.” Medicina (Kaunas, Lithuania) (2021). PMID: 34577842 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [95]
Fukui T, Okubo T, Tanimoto N et al.. “Malignant pleural mesothelioma in a patient with pneumothorax: A cumbersome subtype both clinically and pathologically.” Thoracic cancer (2021). PMID: 33533198 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [96]
Marza AM, Petrica A, Buleu FN et al.. “Case Report: Massive Spontaneous Pneumothorax-A Rare Form of Presentation for Severe COVID-19 Pneumonia.” Medicina (Kaunas, Lithuania) (2021). PMID: 33498180 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [97]
Ha JH, Jeong BH. “Airway Foreign Body Mimicking an Endobronchial Tumor Presenting with Pneumothorax in an Adult: A Case Report.” Medicina (Kaunas, Lithuania) (2021). PMID: 33430107 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [98]
Ferreira JG, Rapparini C, Gomes BM et al.. “Pneumothorax as a late complication of COVID-19.” Revista do Instituto de Medicina Tropical de Sao Paulo (2020). PMID: 32876299 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [99]
Alfehaid M, Salati SA. “Tension faecopneumothorax: an analysis of a rare complication of a missed diaphragmatic injury.” Polski przeglad chirurgiczny (2025). PMID: 41171116 ↗
L5REVIEW_NARRATIVECited in: Differential Diagnosis - [100]
Leopizzi M, Cerbelli B, Merenda E et al.. “Mesenchymal cystic hamartoma presenting with pneumothorax: case report and review of the literature.” General thoracic and cardiovascular surgery (2020). PMID: 32361809 ↗
L4CASE_REPORTCited in: Differential Diagnosis - [101]
Walker S, Hallifax R, Ricciardi S et al.. “Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax.” The European respiratory journal (2024). PMID: 38806203 ↗
L1cGUIDELINECited in: Supportive Care and Complication Management, Guidelines and Resources - [102]
Walker S, Hallifax R, Ricciardi S et al.. “Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax.” European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery (2024). PMID: 38804185 ↗
L1cGUIDELINECited in: Supportive Care and Complication Management, Guidelines and Resources - [103]
Priyadarshi A, Gupta S, Priyadarshini P et al.. “Role of low-pressure negative pleural suction in patients with thoracic trauma - a randomized controlled trial.” European journal of trauma and emergency surgery : official publication of the European Trauma Society (2024). PMID: 38874624 ↗
L1bRCTCited in: Supportive Care and Complication Management, Landmark Trials and Key Evidence - [104]
Damaraju V, Sehgal IS, Muthu V et al.. “Bronchial Valves for Persistent Air Leak: A Systematic Review and Meta-analysis.” Journal of bronchology & interventional pulmonology (2024). PMID: 38716831 ↗
L2aSR_OBSCited in: Supportive Care and Complication Management - [105]
Kawaguchi Y, Hanaoka J, Hayashi K. “Feasibility of early removal of chest tube in the operating room for spontaneous pneumothorax: A prospective randomized controlled study.” Asian journal of surgery (2021). PMID: 32921545 ↗
L1bRCTCited in: Supportive Care and Complication Management - [106]
Kedia Y, Madan M, Kaushik R et al.. “Thoracoscopic blood patch instillation for persistent air leak in pneumothorax: a case series and systematic review.” Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace (2025). PMID: 38656320 ↗
L2aSR_OBSCited in: Supportive Care and Complication Management - [107]
Chen SY, Kuo YW, Ho CC et al.. “Safety and efficacy of vacuum bottle plus catheter for drainage of iatrogenic pneumothorax.” BMC pulmonary medicine (2022). PMID: 35672758 ↗
L2bTRIAL_NONRANDOMCited in: Supportive Care and Complication Management - [108]
Barton EC, Maskell NA, Walker SP. “Expert Review on Spontaneous Pneumothorax: Advances, Controversies, and New Directions.” Seminars in respiratory and critical care medicine (2023). PMID: 37321247 ↗
L5REVIEW_NARRATIVECited in: Supportive Care and Complication Management - [109]
Arakawa S, Matsudaira H, Noda Y et al.. “Catamenial pneumothorax with partial liver herniation due to diaphragmatic laceration: a case report and literature review.” Journal of cardiothoracic surgery (2021). PMID: 33731157 ↗
L4CASE_REPORTCited in: Supportive Care and Complication Management - [110]
Ahmed H, Badran A, Tamburrini A et al.. “Endobronchial Valves in the Management of Persistent Air Leak in Coronavirus Disease 2019.” The Annals of thoracic surgery (2022). PMID: 34492216 ↗
L4CASE_REPORTCited in: Supportive Care and Complication Management - [111]
Laohathai S, Wannadilok P, Poopipatpab S et al.. “Nonintubated Video-Assisted Thoracoscopic Surgery Using Local Anesthesia for Catamenial Pneumothorax.” The Annals of thoracic surgery (2021). PMID: 32971062 ↗
L4CASE_REPORTCited in: Supportive Care and Complication Management - [112]
Long B, Lacy AJ, Mason J et al.. “Tube Thoracostomy and Pleural Catheters: A Review for Emergency Clinicians.” The Journal of emergency medicine (2025). PMID: 40896901 ↗
L5REVIEW_NARRATIVECited in: Supportive Care and Complication Management - [113]
Iqbal B, Hallifax R, Rahman NM. “Pneumothorax: An update on clinical spectrum, diagnosis and management.” Clinical medicine (London, England) (2025). PMID: 40374117 ↗
L5REVIEW_NARRATIVECited in: Supportive Care and Complication Management - [114]
Saha BK, Chong WH, Hu K et al.. “Pressure-dependent persistent air leak in a patient with secondary spontaneous pneumothorax.” The American journal of the medical sciences (2022). PMID: 35787363 ↗
L5REVIEW_NARRATIVECited in: Supportive Care and Complication Management - [115]
Wang J, Zhang Y, Li P et al.. “Effects of respiratory training combined with standard rehabilitation in patients with spontaneous pneumothorax undergoing VATS: A retrospective cohort study.” Medicine (2025). PMID: 41261666 ↗
L2bCOHORTCited in: Supportive Care and Complication Management - [116]
Kahan AM, Kelley-Quon LI, Acker SN et al.. “Pleural drain placement following lung resection in children: A prospective observational study of the Western Pediatric Surgery Research Consortium.” Journal of pediatric surgery (2026). PMID: 40789464 ↗
L5OTHERCited in: Supportive Care and Complication Management - [117]
van Steenwijk QCA, Spaans LN, Heineman DJ et al.. “Population-based study on surgical care for primary spontaneous pneumothorax.” European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery (2024). PMID: 38489837 ↗
L5OTHERCited in: Supportive Care and Complication Management - [118]
Kagan S, Nahum E, Kaplan E et al.. “Persistent pulmonary air leak in the pediatric intensive care unit: Characteristics and outcomes.” Pediatric pulmonology (2021). PMID: 34048635 ↗
L5OTHERCited in: Supportive Care and Complication Management - [119]
Pruitt LCC, Kastenberg ZJ, Fenton SJ et al.. “Early use of autologous blood patch pleurodesis in children is successful in resolving persistent air leaks.” Journal of pediatric surgery (2021). PMID: 33189301 ↗
L5OTHERCited in: Supportive Care and Complication Management - [120]
Norris EA, McEvoy CS, Leatherman ML et al.. “Comparison of 10- versus 14-gauge angiocatheter for treatment of tension pneumothorax and tension-induced pulseless electrical activity with hemorrhagic shock: Bigger is still better.” The journal of trauma and acute care surgery (2020). PMID: 32366761 ↗
L5OTHERCited in: Supportive Care and Complication Management - [121]
Martinez AF, Tom Z, Hsia DW et al.. “Novel Insights from Clinical Practice Autologous Blood Patch Pleurodesis and Endobronchial Valves for Management of Persistent Air Leaks in Two Cases of Tuberculosis.” Respiration; international review of thoracic diseases (2024). PMID: 38417419 ↗
L4CASE_REPORTCited in: Supportive Care and Complication Management - [122]
Zaghba N, Laklaai Z, Chaanoun K et al.. “Pulmonary edema ex vacuo after drainage of pyo-pneumothorax.” BMC pulmonary medicine (2023). PMID: 37974106 ↗
L4CASE_REPORTCited in: Supportive Care and Complication Management - [123]
Fiorelli A, Cannella L, Capasso F et al.. “One-way endobronchial valves in the management of complex persistent air leaks in a soft tissue sarcoma patient.” Thoracic cancer (2023). PMID: 37555456 ↗
L4CASE_REPORTCited in: Supportive Care and Complication Management - [124]
Uzunhan O, Yıldırım MB, Eser C et al.. “A rare cause of air-leak syndrome in a premature newborn: a case report.” BMC pediatrics (2023). PMID: 37442972 ↗
L4CASE_REPORTCited in: Supportive Care and Complication Management - [125]
Shaw JA, Wilken E, Allwood BW et al.. “Autologous Blood Patch Pleurodesis for the Management of a Persistent Air Leak after Secondary Spontaneous Pneumothorax.” Respiration; international review of thoracic diseases (2022). PMID: 34903699 ↗
L4CASE_REPORTCited in: Supportive Care and Complication Management - [126]
Keenan JC, Cho RC, Wong J et al.. “Utility of Functional Pneumonectomy by Using Intrabronchial Valves: First Case Series and Single Center Experience.” Journal of bronchology & interventional pulmonology (2022). PMID: 34879034 ↗
L4CASE_REPORTCited in: Supportive Care and Complication Management - [127]
Donatelli P, Trentacosti F, Pellegrino MR et al.. “Endobronchial valve positioning for alveolar-pleural fistula following ICU management complicating COVID-19 pneumonia.” BMC pulmonary medicine (2021). PMID: 34579700 ↗
L4CASE_REPORTCited in: Supportive Care and Complication Management - [128]
Komiya K, Hamanaka R, Shuto H et al.. “Re-expansion pulmonary edema following a pneumothorax drainage in a patient with COVID-19.” BMC pulmonary medicine (2021). PMID: 34530790 ↗
L4CASE_REPORTCited in: Supportive Care and Complication Management - [129]
Mak KL, Chan JWY, Lau RWH et al.. “Management of bronchopleural fistula with endobronchial valve in hybrid operating room following transbronchial microwave ablation.” Interactive cardiovascular and thoracic surgery (2021). PMID: 34245279 ↗
L4CASE_REPORTCited in: Supportive Care and Complication Management - [130]
Qu D, Chen N, Qiao DF et al.. “Rarely fatal bilateral re-expansion pulmonary edema after inserting a chest tube for unilateral spontaneous pneumothorax: a case report.” Forensic science, medicine, and pathology (2021). PMID: 33170459 ↗
L4CASE_REPORTCited in: Supportive Care and Complication Management - [131]
Wang K, Zhou L, Zhu M et al.. “Medical Thoracoscopy With vs Without Prior Artificial Pneumothorax for Patients With Minimal or Absent Pleural Effusion.” Chest (2026). PMID: 40712947 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [132]
Arora D, Choudhary IS, Dutt A et al.. “Efficacy of slow negative pleural suction in thoracic trauma patients undergoing tube thoracostomy-A randomised clinical trial.” Injury (2025). PMID: 39393972 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [133]
Bian Y, Deng M, Gao Q et al.. “The Diagnostic Efficiency and Safety of Transbronchial Lung Cryobiopsy Using 1.1-mm Cryoprobe in Diagnosing Interstitial Lung Disease.” Lung (2024). PMID: 38910197 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [134]
Kaluarachchi DC, Gerday E, Bahr T et al.. “High vs low CPAP strategy with aerosolized calfactant in preterm infants with respiratory distress syndrome.” Journal of perinatology : official journal of the California Perinatal Association (2025). PMID: 38594414 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [135]
Li X, Yang H, Cai Y et al.. “Chest tube removal at different gas flows in prolonged air leak: a randomized non-inferiority trial.” European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery (2024). PMID: 38479816 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [136]
Vitali F, Malagù M, Bianchi N et al.. “Ultrasound-Guided Venous Axillary Access Versus Standard Fluoroscopic Technique for Cardiac Lead Implantation: ZEROFLUOROAXI Randomized Trial.” JACC. Clinical electrophysiology (2024). PMID: 38243998 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [137]
Ravaglia C, Sultani F, Piciucchi S et al.. “Diagnostic yield and safety of transbronchial lung cryobiopsy for diffuse parenchymal lung diseases diagnosis: Comparison between 1.7-mm and 1.9-mm probes.” Pulmonology (2025). PMID: 37210342 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [138]
Marx T, Joly LM, Parmentier AL et al.. “Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial.” American journal of respiratory and critical care medicine (2023). PMID: 36693146 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [139]
Luengo-Fernandez R, Landeiro F, Hallifax R et al.. “Cost-effectiveness of ambulatory care management of primary spontaneous pneumothorax: an open-label, randomised controlled trial.” Thorax (2022). PMID: 35354647 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [140]
Ren Y, Zhu X, Yan H et al.. “Cardiorespiratory impact of intrathoracic pressure overshoot during artificial carbon dioxide pneumothorax: a randomized controlled study.” BMC anesthesiology (2022). PMID: 35321653 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [141]
Dheur S, Gérard L, Lamborelle P et al.. “Track Sealing in CT-Guided Lung Biopsy Using Gelatin Sponge Slurry versus Saline in Reducing Postbiopsy Pneumothorax: A Prospective Randomized Study.” Journal of vascular and interventional radiology : JVIR (2024). PMID: 39074550 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [142]
Sabzevari F, Eslamian M, Karami Robati F et al.. “Comparison of the efficacy of two natural surfactants (BERAKSURF and BLES) in the treatment of respiratory distress syndrome among preterm neonates.” BMC pediatrics (2023). PMID: 38036980 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [143]
Zuo C, Xue K, Yang H et al.. “Clinical Application of Confocal Laser Endomircoscopy Combined with Cryobiopsy in the Diagnosis of Interstitial Lung Disease.” Respiration; international review of thoracic diseases (2023). PMID: 37757757 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [144]
Zhang YS, Zhang SL, Guo WM et al.. “Clinical Effect of Modified Ultrasound-Guided Subclavian Vein Puncture.” International journal of clinical practice (2023). PMID: 37457808 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [145]
Yang F, Wang X, Xu H et al.. “A novel drainage strategy using chest tube plus pleural catheter in uniportal upper lobectomy: A randomized controlled trial.” Thoracic cancer (2023). PMID: 36562112 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [146]
Herath S, Wong C, Dawkins P et al.. “Cryobiopsy with radial-endobronchial ultrasound (Cryo-Radial) has comparable diagnostic yield with higher safety in comparison to computed tomography-guided transthoracic biopsy for peripheral pulmonary lesions: An exploratory randomised study.” Internal medicine journal (2023). PMID: 35675149 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [147]
Harrison M. “Non-Invasive Management of Blunt Traumatic Pneumothorax-a Meta-Analysis.” Emergency medicine Australasia : EMA (2025). PMID: 41163445 ↗
L2aSR_OBSCited in: Landmark Trials and Key Evidence - [148]
Bosso G, Sansone G, Papillo M et al.. “Lung ultrasound-guided PEEP titration in COVID-19 patients treated with CPAP.” Journal of basic and clinical physiology and pharmacology (2023). PMID: 37463298 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [149]
Blythe NM, Coates K, Benger JR et al.. “Conservative management versus invasive management of significant traumatic pneumothoraces in the emergency department (the CoMiTED trial): a study protocol for a randomised non-inferiority trial.” BMJ open (2024). PMID: 38889939 ↗
L2bTRIAL_NONRANDOMCited in: Landmark Trials and Key Evidence - [150]
Azat Azrai A, Mas Fazlin MJ, Nik Azuan I et al.. “Thoracic vent versus conventional intercostal tube drainage in management of pneumothorax in a tertiary referral centre.” The Medical journal of Malaysia (2025). PMID: 41328847 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [151]
Çıtak N, Özdemir S, Köse S. “Could the probability of surgical indication be determined after first episode of primary spontaneous pneumothorax?” General thoracic and cardiovascular surgery (2023). PMID: 36807111 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [152]
Sun YL, Sun L, Li TK et al.. “[Efficacy of two-lung ventilation with different tidal volume assisted by CO2 pneumothorax for airway management in patients undergoing radical resection of esophageal cancer using combined laparoscopic and thoracoscopic approach].” Zhonghua yi xue za zhi (2021). PMID: 34551495 ↗
L1bRCTCited in: Landmark Trials and Key Evidence - [153]
Flume PA, Mogayzel PJ, Robinson KA et al.. “Cystic fibrosis pulmonary guidelines: pulmonary complications: hemoptysis and pneumothorax.” American journal of respiratory and critical care medicine (2010). PMID: 20675678 ↗
L1cGUIDELINECited in: Guidelines and Resources - [154]
Kelly AM. “Review of management of primary spontaneous pneumothorax: is the best evidence clearer 15 years on?” Emergency medicine Australasia : EMA (2007). PMID: 17655631 ↗
L1cGUIDELINECited in: Guidelines and Resources - [155]
Lee C, Revell M, Porter K et al.. “The prehospital management of chest injuries: a consensus statement. Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh.” Emergency medicine journal : EMJ (2007). PMID: 17351237 ↗
L1cGUIDELINECited in: Guidelines and Resources - [156]
Andrade Filho LO, de Campos JR, Haddad R. “[Pneumothorax].” Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia (2006). PMID: 17273626 ↗
L1cGUIDELINECited in: Guidelines and Resources - [157]
Frykholm P, Pikwer A, Hammarskjöld F et al.. “Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine.” Acta anaesthesiologica Scandinavica (2014). PMID: 24593804 ↗
L1cGUIDELINECited in: Guidelines and Resources - [158]
van Dijk M, Sue R, Criner GJ et al.. “Expert Statement: Pneumothorax Associated with One-Way Valve Therapy for Emphysema: 2020 Update.” Respiration; international review of thoracic diseases (2021). PMID: 34062550 ↗
L1cGUIDELINECited in: Guidelines and Resources - [159]
Schnell J, Beer M, Eggeling S et al.. “Management of Spontaneous Pneumothorax and Post-Interventional Pneumothorax: German S3 Guideline.” Respiration; international review of thoracic diseases (2019). PMID: 30041191 ↗
L1cGUIDELINECited in: Guidelines and Resources - [160]
Agrafiotis AC, Assouad J, Lardinois I et al.. “Pneumothorax and Pregnancy: A Systematic Review of the Current Literature and Proposal of Treatment Recommendations.” The Thoracic and cardiovascular surgeon (2021). PMID: 32199405 ↗
L1cGUIDELINECited in: Guidelines and Resources - [161]
Rivas de Andrés JJ, Jiménez López MF, Molins López-Rodó L et al.. “[Guidelines for the diagnosis and treatment of spontaneous pneumothorax].” Archivos de bronconeumologia (2008). PMID: 18775256 ↗
L1cGUIDELINECited in: Guidelines and Resources - [162]
Schnell J, Beer M, Eggeling S et al.. “Management of Spontaneous Pneumothorax and Postinterventional Pneumothorax: German S3-Guideline.” Zentralblatt fur Chirurgie (2018). PMID: 30041262 ↗
L1cGUIDELINECited in: Guidelines and Resources - [163]
Aguinagalde B, Aranda JL, Busca P et al.. “SECT Clinical practice guideline on the management of patients with spontaneous pneumothorax.” Cirugia espanola (2018). PMID: 29248330 ↗
L1cGUIDELINECited in: Guidelines and Resources - [164]
Sandig J, Bührer C, Czernik C. “[Lung Ultrasound in Neonatology to diagnose a Pneumothorax (part two): A Guideline].” Zeitschrift fur Geburtshilfe und Neonatologie (2021). PMID: 33352591 ↗
L1cGUIDELINECited in: Guidelines and Resources - [165]
Josephs LK, Coker RK, Thomas M. “Managing patients with stable respiratory disease planning air travel: a primary care summary of the British Thoracic Society recommendations.” Primary care respiratory journal : journal of the General Practice Airways Group (2013). PMID: 23732637 ↗
L1cGUIDELINECited in: Guidelines and Resources - [166]
Robinson PD, Blackburn C, Babl FE et al.. “Management of paediatric spontaneous pneumothorax: a multicentre retrospective case series.” Archives of disease in childhood (2015). PMID: 25670402 ↗
L4CASE_REPORTCited in: Guidelines and Resources - [167]
Ng C, Tsung JW. “Point-of-care ultrasound for assisting in needle aspiration of spontaneous pneumothorax in the pediatric ED: a case series.” The American journal of emergency medicine (2014). PMID: 24360316 ↗
L4CASE_REPORTCited in: Guidelines and Resources - [168]
Haynes D, Baumann MH. “Management of pneumothorax.” Seminars in respiratory and critical care medicine (2010). PMID: 21213209 ↗
L5REVIEW_NARRATIVECited in: Guidelines and Resources - [169]
Wood DE, Cerfolio RJ, Gonzalez X et al.. “Bronchoscopic management of prolonged air leak.” Clinics in chest medicine (2010). PMID: 20172438 ↗
L5REVIEW_NARRATIVECited in: Guidelines and Resources - [170]
Kelly AM, Druda D. “Comparison of size classification of primary spontaneous pneumothorax by three international guidelines: a case for international consensus?” Respiratory medicine (2008). PMID: 18789858 ↗
L5OTHERCited in: Guidelines and Resources - [171]
Young LR, Almoosa KF, Pollock-Barziv S et al.. “Patient perspectives on management of pneumothorax in lymphangioleiomyomatosis.” Chest (2006). PMID: 16685018 ↗
L5OTHERCited in: Guidelines and Resources - [172]
Hooper C, Maskell N. “British Thoracic Society national pleural procedures audit 2010.” Thorax (2011). PMID: 21474495 ↗
L5OTHERCited in: Guidelines and Resources - [173]
Alan N, Farber SH, Zhou JJ et al.. “Incidence of radiographic and clinically significant pneumothorax or hemothorax after thoracic discectomy via mini-open lateral retropleural approach without prophylactic chest tube placement.” Journal of neurosurgery. Spine (2024). PMID: 38905710 ↗
L5OTHERCited in: Guidelines and Resources - [174]
Nikolić MZ, Lok LS, Mattishent K et al.. “Noninterventional statistical comparison of BTS and CHEST guidelines for size and severity in primary pneumothorax.” The European respiratory journal (2015). PMID: 25792629 ↗
L5OTHERCited in: Guidelines and Resources