A pneumothorax is air in the pleural space. Normally the pleural space holds slightly negative (subatmospheric) pressure that keeps the lung expanded against the chest wall. When air enters, that negative pressure is lost and the lung partly or completely collapses, reducing ventilation and causing hypoxemia.
| Type | Cause | Typical client |
|---|
| Primary spontaneous (PSP) | Rupture of small subpleural blebs at the lung apex, no known lung disease | Tall, thin young male, often a smoker (tobacco or cannabis) |
| Secondary spontaneous (SSP) | Rupture from underlying lung disease | COPD/emphysema (most common), cystic fibrosis, TB, pneumonia, ILD; older clients; more dangerous because reserve is low |
| Traumatic | Blunt or penetrating chest injury; iatrogenic — central line insertion, thoracentesis, lung biopsy, mechanical ventilation (barotrauma) | Any |
| Open pneumothorax ("sucking chest wound") | Chest wall wound lets atmospheric air move in and out | Penetrating trauma |
| Tension pneumothorax | A one-way valve lets air enter but not leave; pressure builds, collapses the lung, pushes the mediastinum to the opposite side, kinks the great veins → ↓venous return → obstructive shock | Ventilated clients, trauma, clamped or blocked chest tube, fully sealed dressing on an open wound |
Related: hemothorax (blood), hemopneumothorax, pleural effusion, empyema — also drained with chest tubes.
Recurrence: PSP recurs in about one-third of clients; stopping smoking substantially lowers the risk.
Simple pneumothorax
- Sudden, sharp, pleuritic chest pain on the affected side
- Dyspnea, tachypnea, tachycardia, anxiety
- Decreased or absent breath sounds on the affected side
- Hyperresonance to percussion
- Asymmetrical chest expansion
- Subcutaneous emphysema (crackling under the skin) possible
- Small PSP may cause only mild symptoms
Tension pneumothorax — emergency
- Severe, worsening respiratory distress, hypotension, tachycardia
- Tracheal deviation toward the unaffected (opposite) side (late sign)
- Distended neck veins (may be absent with hypovolemia)
- Absent breath sounds and hyperresonance on the affected side
- Cyanosis, falling SpO₂; in ventilated clients — sudden rise in airway pressures
- Diagnose clinically — do not delay decompression for an X-ray
| Test | Finding |
|---|
| Chest X-ray (upright) | Visible visceral pleural line with no lung markings beyond it; size estimation |
| Lung ultrasound (point of care) | Absent lung sliding, "lung point" |
| CT chest | Small or loculated pneumothorax, underlying bullae, trauma |
| ABG / SpO₂ | Hypoxemia; respiratory alkalosis from hyperventilation early |
Current guidelines (British Thoracic Society 2023; European 2024) base treatment on symptoms and physiological stability, not only on size.
Primary spontaneous pneumothorax
- Minimal symptoms, stable: conservative management (observation, pain relief, follow-up X-ray) can be used regardless of size
- Symptomatic: needle aspiration, an ambulatory drainage device, or a small-bore chest tube
- Supplemental oxygen during observation speeds reabsorption of pleural air (oxygen lowers nitrogen in the blood, increasing the gradient for pleural gas absorption) — use target-based oxygen in clients with COPD
Secondary spontaneous pneumothorax: usually admitted and drained with a chest tube; surgery earlier for persistent leak.
Tension pneumothorax: immediate needle decompression (adult site: 4th or 5th intercostal space just anterior to the midaxillary line, or 2nd intercostal space in the midclavicular line) or finger thoracostomy, followed by chest tube insertion.
Open pneumothorax: cover with a vented chest seal or a dressing taped on three sides (flutter valve — air escapes on expiration, the flap seals on inspiration), then chest tube. Fully occluding the wound can create a tension pneumothorax.
Recurrence prevention: VATS (video-assisted thoracoscopic surgery) with bullectomy and pleurodesis (mechanical or chemical, e.g., talc) — for recurrence, persistent air leak (> 3–5 days), bilateral pneumothorax, or high-risk occupations such as pilots and divers.
Analgesia: NSAIDs or opioids as needed. NSAIDs: GI bleeding, kidney injury — avoid in active bleeding and advanced kidney disease. Opioids: respiratory depression — monitor sedation and respiratory rate.
Listed in priority order.
- Breathing and oxygenation
- Position upright (semi- to high-Fowler's) and give oxygen — this comes before analgesia, IV access, or teaching
- Monitor RR, SpO₂, breath sounds, chest expansion, vital signs
- Watch continuously for tension pneumothorax signs; call for emergency help immediately if they appear
- Assist with chest tube insertion — consent, analgesia, sterile field, position (usually supine or semi-upright with arm raised above head); tube commonly placed in the 4th–5th intercostal space mid- to anterior axillary line
- Chest drainage system care (below)
- Pain control so the client can breathe deeply, cough, and move
- Pulmonary hygiene — deep breathing, incentive spirometry, coughing; early ambulation with the drainage system kept below chest level
- Assess the insertion site — dressing dry and intact, subcutaneous emphysema (mark its edges and report spreading), signs of infection
Chest drainage system — how it works
| Chamber | Normal findings | Abnormal findings |
|---|
| Collection | Drainage amount, color recorded (mark level) | Sudden increase in bloody drainage (commonly > 100 mL/h, or per provider threshold); sudden stop of expected drainage (possible clot or kink) |
| Water seal (about 2 cm water; one-way valve) | Tidaling: fluid rises on inspiration and falls on expiration (reversed on positive-pressure ventilation). Intermittent bubbling on exhalation or coughing in a client with pneumothorax = air leaving the pleural space | Continuous bubbling = air leak (from the client or the system). No tidaling = lung re-expanded or obstruction (kink, clot, dependent loop) |
| Suction control — wet (water column, often 20 cm) or dry (dial, often −20 cmH₂O) | Wet: gentle continuous bubbling; dry: indicator shows set level | Vigorous bubbling (wet) evaporates water — reduce the wall suction; dry: indicator not expanded |
Key rules
- Keep the drainage unit upright and below the chest at all times; keep tubing without kinks and without dependent loops, coiled on the bed
- Do not clamp the chest tube for transport or ambulation — clamping can cause tension pneumothorax. Brief clamping is used only when ordered or per policy (e.g., locating a leak, changing a unit)
- Do not routinely milk or strip tubing; follow facility policy
- Tidaling stops suddenly: assess the client first (breathing, SpO₂); check for kinks, clots, dependent loops, or the client lying on the tubing; have the client take deep breaths and cough; notify if not resolved — it may also mean the lung has re-expanded (confirm with X-ray)
- New continuous bubbling: assess the client; check connections from the insertion site down to the unit; notify provider
- Tube disconnects from the drainage unit: immerse the tube end 2–3 cm in sterile water (or reconnect quickly) and set up a new system; assess the client
- Tube pulls out of the chest: cover the site immediately with a sterile dressing (taped on three sides or per policy), assess for respiratory distress, notify provider
- Unit tips over: set upright, check water-seal level, notify if needed
- Keep sterile water, sterile dressing, and (if policy) clamps at the bedside
Chest tube removal
- Criteria (all together): no air leak (no bubbling in the water seal, even with coughing, typically for about 24 hours), lung re-expanded on chest X-ray, drainage below the provider's threshold, client clinically stable
- Premedicate for pain; the client performs a Valsalva maneuver or holds the breath (end-inspiration or end-expiration per provider technique) while the tube is pulled
- Apply an occlusive dressing; obtain X-ray; monitor for recurrent pneumothorax
- Seek emergency care immediately for sudden chest pain or shortness of breath — recurrence is common
- Stop smoking (tobacco and cannabis) — the most important modifiable risk factor for recurrence
- Avoid air travel until the provider confirms complete resolution — commonly about 1–2 weeks after resolution on X-ray; airlines may require clearance
- Scuba diving is generally avoided permanently unless definitive surgery has been done; discuss with the provider
- Avoid heavy lifting and strenuous activity until cleared; light walking can be resumed gradually
- Keep follow-up X-ray appointments
- Know which activities to discuss with the provider before resuming (contact sports, high altitude)
| Complication | What to watch for |
|---|
| Tension pneumothorax | Hypotension, tracheal shift away from affected side, JVD, severe distress — emergency decompression |
| Persistent air leak / bronchopleural fistula | Continuous bubbling beyond several days |
| Re-expansion pulmonary edema | Cough, dyspnea, hypoxemia soon after rapid drainage of a large, long-standing pneumothorax |
| Hemorrhage | Rapidly increasing bloody drainage, hypotension |
| Infection / empyema | Fever, purulent drainage, site redness |
| Subcutaneous emphysema | Spreading crepitus to neck or face |
| Recurrence | Same symptoms after discharge |
- Classic PSP: tall, thin young male smoker; SSP: COPD most common
- Signs: sudden pleuritic pain, dyspnea, ↓/absent breath sounds, hyperresonance
- Tension pneumothorax: hypotension, tachycardia, JVD, trachea shifts to the opposite side → immediate needle decompression, then chest tube; don't wait for an X-ray
- Priority: upright position and oxygen
- Open chest wound: vented seal or three-sided dressing; watch for tension
- Tidaling = normal; stops → lung re-expanded or tubing obstructed
- Continuous bubbling in the water seal = air leak; gentle continuous bubbling in the wet suction chamber = normal
- Drainage unit upright and below chest; never clamp for routine transport
- Disconnected tube → submerge end 2–3 cm in sterile water
- Removal requires no air leak and re-expanded lung
- Minimally symptomatic PSP may be observed regardless of size (2023 guidance)
- Smoking cessation lowers recurrence
Country Notes
United States
- Commercial airlines and diving organizations follow provider clearance; clients should carry discharge documentation when traveling soon after treatment.
- Dry-suction chest drainage systems are often used in US hospitals; wet-suction units are still used in some settings, so confirm the system type before assessing.
Philippines
- Tuberculosis is an important cause of secondary spontaneous pneumothorax; assess TB history and use airborne precautions until TB is excluded in clients with suggestive findings.
- Wet (water-column) suction systems and bottle systems are often still used in many facilities; check water levels each shift.