BTS Guidelines for Pneumothorax (2023)

1. Classification

Key 2023 change: Patients aged >50 years with a significant smoking history should be managed as SSP even if no formal diagnosis of lung disease is documented, due to likely underlying COPD.

2. Diagnosis

• The 2023 BTS guideline no longer recommends using the interpleural distance at the hilum (old 2cm rule) as the primary size threshold for determining management.
• CT thorax is preferred if there is doubt about CXR findings, or to characterize any bullous disease.
• Point-of-care ultrasound (POCUS): absence of "pleural sliding" is the key sign. The "lung point" (presence of sliding on one side, absence on the other) is highly specific for pneumothorax. The "barcode/stratosphere sign" on M-mode (absence of the normal "seashore sign") is confirmatory. POCUS is especially useful in trauma and ICU settings.

3. Acute Management - The 2023 Algorithm

Step 1: Assess Symptoms

• Conservative management can be considered for PSP of any size
  • Requires intensive follow-up via Ambulatory/Respiratory Clinic
  • Re-imaging in 2-4 weeks to confirm resolution
• SSP: conservative management still possible but requires inpatient admission for monitoring given higher risk of deterioration

• Proceed to active intervention (see below)

Step 2: Active Intervention Options (in order of invasiveness)

A) Ambulatory Management (preferred active option for PSP)

• Use a small-bore ambulatory device (Heimlich valve or similar one-way valve device)
• Allows outpatient management in selected PSP patients with good support systems and follow-up access
• Conditional recommendation - centre expertise required

B) Needle Aspiration

• Suitable for PSP and SSP patients not fit for, or declining, ambulatory management
• Use a 16G cannula inserted in the 2nd intercostal space, mid-clavicular line (or 4th-5th ICS, anterior axillary line)
• Aspirate with 50 ml syringe; measure total volume removed
• If > 2.5 litres aspirated without resistance - suggests significant persistent air leak; consider tube drainage
• Stop and obtain CXR; if expanded - may remove cannula
• For large pneumothorax, consider proceeding directly to Seldinger drain rather than needle aspiration (small-bore, no more painful)

C) Chest Drain (Tube Thoracostomy)

• Indicated when: aspiration fails, very large pneumothorax, SSP with haemodynamic compromise, ongoing air leak, mechanically ventilated patients
• Small-bore Seldinger drains (10-14F) are preferred over large-bore surgical drains for spontaneous pneumothorax
• Connect to underwater seal - avoid suction initially unless drain is not functioning or there is a large persistent air leak
• If suction needed: use -20 cmH2O
• Drain removal: once air leak has resolved and lung is re-expanded on CXR; clamp for 4-6 hours and re-image before removal

4. Tension Pneumothorax

• Tachycardia, hypotension (late sign)
• Tracheal deviation away from the affected side
• Absent/reduced breath sounds on the affected side
• Jugular venous distension
• Elevated peak airway pressures (if ventilated)
• Hyper-resonance on percussion

1. Immediate needle decompression: 14-16G cannula, 2nd intercostal space, mid-clavicular line (or 4th ICS, anterior axillary line in obese patients)
2. Follow with formal chest drain insertion as definitive management
3. In patients on positive pressure ventilation (PPV), even a simple pneumothorax should be drained urgently - it can rapidly progress to tension pneumothorax

5. Management by Type: Summary Table

6. Recurrence Prevention

Chemical Pleurodesis

• Conditional recommendation for SSP patients (especially severe COPD with significant decompensation)
• Can be done via drain using talc slurry (preferred agent) or tetracycline
• Adequate analgesia must be given before and after pleurodesis
• Not routinely recommended after first PSP

Surgical Management (VATS or Thoracotomy)

7. Special Populations

8. Discharge and Follow-Up Advice

• Increased symptoms: immediate return to ED
• Air travel: avoid until complete resolution confirmed on imaging
• Scuba diving: permanent ban unless the patient has had bilateral surgical pleurodesis (pleurectomy) and normal follow-up CT - this applies to PSP and SSP alike
• Driving: patients should not drive until resolution confirmed (DVLA guidance)
• Follow-up arranged via Respiratory Clinic or Ambulatory Respiratory Care (mSDEC equivalent)

Recent Evidence Updates

1. [Sys Review - 2023] Observation vs. Aspiration vs. Tube Thoracostomy for PSP - meta-analysis confirming aspiration and observation are both valid first-line options for PSP, supporting the 2023 BTS shift away from routine tube drainage. [PMID: 37209773]
2. [Sys Review - 2024] Simple aspiration for spontaneous pneumothorax - meta-analysis of RCTs confirming aspiration is effective, with similar success to chest drain but shorter hospital stay. [PMID: 38537340]
3. [Sys Review - 2023] PSP management in adolescents/young adults (APSA guidelines) - reaffirms conservative approach where appropriate. [PMID: 37130765]

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6e (management of PPV-related and tension pneumothorax)
• Murray & Nadel's Textbook of Respiratory Medicine (POCUS diagnosis of pneumothorax)