A pneumothorax occurs when the visceral or parietal pleurae are breached and air enters the pleural space. This leads to loss of the negative intrapleural pressure and lung collapse. Pneumothoraces are classified according to the aetiology as spontaneous (which may be primary or secondary depending on the underlying pathology) or traumatic. Further descriptive terms such as tension, open or sucking describe features of the pneumothorax that may guide management.
A chest X-ray is essential in the diagnosis and management of any pneumothorax, with the strict exception of tension pneumothoraces. These are clinical emergencies that should be diagnosed clinically and decompressed immediately with needle thoracocentesis without delay for imaging. Chest drains are the definitive management for complex pneumothoraces and are indicated when aspiration is unsuccessful in controlling symptoms in a simple pneumothorax. A thoracic surgical opinion should be sought if there is persistent air leak from the drain or the lung fails to re-expand after 3 days.
Chest drains (also known as intercostal drains, pleural drains or tube thoracostomy) may be used to drain air, blood, fluid or pus from the pleural space. Although insertion of a chest drain is a common procedure, the risk of injury or death may be up to 2% and has been the subject of a National Patient Safety Agency (NPSA) Rapid Response Report. Proper attention should be paid therefore to patient preparation, which should include full consent, asepsis, appropriate patient positioning, and application of NPSA and British Thoracic Society recommendations. Ultrasound guidance is recommended for effusions, but is not required for pneumothoraces. The procedure is usually performed under local anaesthesia in the ‘safe triangle’ of the lateral chest wall using a Seldinger technique or blunt dissection. Following insertion, careful attention must also be paid to the management of the chest drain.