Pneumothorax Nursing Guide

Definition & Classification

A pneumothorax is air in the pleural space. It can be spontaneous (primary or secondary) or traumatic/iatrogenic.

Type	Description	Risk Group
Primary Spontaneous (PSP)	No underlying lung disease; blebs rupture	Tall, thin young men (20–30 yrs); smokers; Marfan syndrome
Secondary Spontaneous (SSP)	Underlying lung disease	COPD ⭐ (most common), asthma, CF, TB, PCP (HIV), malignancy
Traumatic	Chest wall injury, rib fractures	RTC, penetrating injury, falls
Iatrogenic	Procedure-related	Central line insertion (subclavian/IJV), thoracocentesis, lung biopsy, positive pressure ventilation (ventilator-induced)
Tension	Air accumulates under pressure → mediastinal shift → cardiac arrest	Ventilated patients, trauma, penetrating chest wound

Symptoms

Sudden onset pleuritic chest pain (ipsilateral)
Dyspnoea — mild in PSP; severe in SSP (pre-existing reduced reserve) or tension
Tachycardia
Hypoxia (SpO₂ drop)

Examination Findings

Reduced breath sounds on affected side
Hyper-resonance to percussion (air) — opposite of dullness in pleural effusion
Reduced chest expansion on affected side
Trachea: midline in simple; deviated AWAY from tension pneumothorax

Tension Pneumothorax — Recognition

A one-way valve effect causes progressive air accumulation under pressure → lung collapses completely → mediastinum shifts → compresses great veins → reduced venous return → obstructive shock → cardiac arrest.

Classic Signs (5 Ts)

Tachycardia (early) → bradycardia (pre-arrest)
Tracheal deviation AWAY from affected side (late sign)
Tension: hypotension, rising respiratory distress
Tympanic (hyper-resonance) on affected side
Tightness: absent breath sounds on affected side

ABSENT or DISPLACED JVP (raised JVP) + ABSENT breath sounds + TRACHEAL DEVIATION + HAEMODYNAMIC COLLAPSE = Tension pneumothorax until proven otherwise. DO NOT wait for CXR.

Emergency Management

STEP 1 — Immediate Needle Decompression (Thoracocentesis)

Large-bore cannula (14–16G) inserted at 2nd intercostal space, mid-clavicular line (MCL) on affected side
Rush of air confirms tension pneumothorax
Relieves tension and buys time for definitive chest drain
Alternative site: 4th/5th ICS, anterior axillary line (less risk of injury if obese)

STEP 2 — Definitive Chest Drain

Insert intercostal chest drain (Seldinger or surgical) at 4th/5th ICS, anterior axillary line (safe triangle)
Connect to underwater seal drainage
Post-procedure CXR to confirm lung re-expansion

Investigations & Sizing

CXR Findings

Visible lung edge with absent lung markings peripheral to it
Deviation of heart/trachea (tension) — away from pneumothorax
Mediastinal shift indicates tension or large pneumothorax

Pneumothorax Size (BTS Classification)

Size	Definition	Action
Small	Rim < 2 cm on CXR (PSP); < 1 cm (SSP)	Discharge (PSP if no symptoms); admission/aspiration (SSP)
Large	Rim ≥ 2 cm (PSP); ≥ 1 cm (SSP)	Aspiration or chest drain

SSP requires lower threshold for intervention — even small pneumothorax in COPD or fibrosis can cause life-threatening respiratory compromise due to reduced reserve. Admit all SSP.

Management Algorithm

PSP (Healthy Young Patient)

Small + no symptoms: discharge, review in 2 weeks, avoid air travel 6 weeks
Large or symptomatic: needle aspiration first (16G cannula, 2nd ICS MCL, aspirate up to 2.5 L) → repeat CXR → if re-expanded, discharge
Failed aspiration (lung not re-expanded): intercostal chest drain

SSP (Underlying Lung Disease)

All SSP: admit to hospital, high-flow O₂ to encourage nitrogen washout (speeds re-expansion)
Small + minimal dyspnoea: observation
Large or breathless: chest drain

Chest Drain Care — Key Nursing Points

Keep drain below chest level; ensure underwater seal intact
Swinging: water level swings with respiration = patent drain
Bubbling: continuous bubbling during expiration = air leak draining (normal); persistent bubbling at rest = bronchopleural fistula or disconnection
No swinging + no bubbling = blocked or kinked tube — flush/reposition
NEVER clamp chest drain for pneumothorax (tension risk)
Drain removal: when bubbling stops, lung re-expanded on CXR, drainage <150 mL/24 hrs (empyema)
Remove drain on expiration or during Valsalva; apply vaseline gauze dressing

NEVER clamp a chest drain for a pneumothorax — tension pneumothorax can rapidly develop.

High-Flow Oxygen in Pneumothorax

High-flow O₂ (100% via non-rebreather mask) quadruples the rate of pneumothorax resolution by flushing nitrogen from the pleural space. Use in hospital-managed patients. Note: do NOT use 100% O₂ in COPD patients with hypercapnia (SpO₂ target 88–92%).

GCC-Specific Pneumothorax Context

Shisha/waterpipe smoking — associated with bullous emphysema and increased spontaneous pneumothorax risk. Popular in GCC countries, particularly among young men and increasingly women. Shisha produces 100× more smoke per session than cigarettes.
COPD-related SSP — rising COPD prevalence in GCC from tobacco and shisha use; SSP complicating COPD carries high mortality in this population.
Iatrogenic after central line insertion — subclavian and internal jugular central venous access is a common cause of iatrogenic pneumothorax. Bedside CXR after every subclavian line insertion is mandatory. Ultrasound guidance significantly reduces pneumothorax risk.
Ventilator-associated pneumothorax (barotrauma) — common complication in ARDS ventilated patients in GCC ICUs. Lung-protective ventilation (tidal volume 6 mL/kg IBW, plateau pressure <30 cmH₂O) reduces risk.
Hajj/mass gathering trauma — rib fractures from crowd trauma at Hajj can cause haemopneumothorax. Hajj medical teams must be prepared for emergency chest drain insertion in field conditions.

MCQ Practice — Pneumothorax

Q1. A ventilated patient in the ICU suddenly develops tachycardia, profound hypotension, absent breath sounds on the left, and tracheal deviation to the right. What is the IMMEDIATE action?

A) Urgent CXR to confirm diagnosis before treatment

B) Immediate needle decompression: 14G cannula at 2nd ICS mid-clavicular line on the LEFT

C) Increase PEEP to reinflate the lung

D) Emergency intubation and bronchoscopy

✅ B — Clinical tension pneumothorax: absent breath sounds LEFT + tracheal deviation RIGHT (away from tension) + haemodynamic collapse. This is a clinical diagnosis — DO NOT wait for CXR. Immediate needle decompression at 2nd ICS MCL on the AFFECTED (left) side. Then insert chest drain.

Q2. A 26-year-old tall slim man has a sudden right-sided chest pain and mild dyspnoea. CXR shows a right pneumothorax with a 2.5 cm rim. No underlying lung disease. What is the first-line treatment?

A) Immediate chest drain insertion

B) Discharge with follow-up — no intervention needed

C) Needle aspiration (16G, 2nd ICS MCL, up to 2.5 L)

D) High-flow O₂ only and re-image in 6 hours

✅ C — Large PSP (≥2 cm rim) in a symptomatic patient: first-line = needle aspiration. If successful re-expansion on repeat CXR → discharge. If failed → chest drain. Chest drain is not first-line in uncomplicated PSP.

Q3. A chest drain for pneumothorax shows persistent continuous bubbling even at rest (not just on expiration). What does this indicate?

A) Normal functioning drain — continue monitoring

B) Drain is blocked — flush with saline

C) Persistent air leak — bronchopleural fistula or drain disconnection

D) Lung has fully re-expanded — remove drain

✅ C — Bubbling during expiration = air draining normally. Continuous bubbling at rest = ongoing air leak from bronchopleural fistula or tubing disconnection. Check all connections first; if intact, notify thoracic surgery — may need pleurodesis or surgical repair.

Q4. In a patient with COPD developing a secondary spontaneous pneumothorax, high-flow 100% oxygen is administered. What is the benefit AND the specific risk?

A) Benefit: prevents infection. Risk: reduces haemoglobin saturation

B) Benefit: accelerates nitrogen washout speeding pneumothorax resolution. Risk: hypercapnic respiratory failure in COPD (O₂-sensitive patients)

C) Benefit: prevents re-expansion oedema. Risk: fire hazard in hospital

D) Benefit: reduces pleuritic pain. Risk: paradoxical embolism

✅ B — High-flow O₂ flushes nitrogen from the pleural space, accelerating resolution. However, COPD patients with hypercapnia can develop CO₂ retention and respiratory failure if given high-flow O₂ (they rely on hypoxic drive). Target SpO₂ 88–92% in COPD patients — use controlled O₂ via Venturi mask.

Pneumothorax — Nursing Guide