Pneumothorax Management Medical Slides

The PSP trial (Brown 2020, NEJM) randomized moderate primary spontaneous pneumothorax to conservative management (observation + analgesia) versus interventional management (aspiration ± chest tube). Conservative management was non-inferior for lung re-expansion at 8 weeks (98.5% vs 94.6%), with lower intervention rates, shorter hospital stays, and fewer recurrences at 12 months. Present this as a paradigm shift — stable patients with moderate PSP can be safely observed.

Present the clinical diagnosis (do not delay for imaging): hypotension, tracheal deviation, absent breath sounds, distended neck veins, tachycardia. Immediate needle decompression: 14-16G needle in the 2nd intercostal space midclavicular line (note: 4th-5th ICS anterior axillary line may be more reliable due to chest wall thickness — ACS recommendation). Follow with chest tube insertion. Emphasize that tension pneumothorax is a clinical diagnosis requiring immediate action.

Present recurrence rates: 30-50% after first PSP, 60-80% after second episode. Risk factors: continued smoking (reduces recurrence risk by 40% if ceased), tall stature, low BMI, visible blebs on CT. Intervention indications: second ipsilateral episode, bilateral pneumothorax, persistent air leak >5-7 days, hemopneumothorax. VATS with pleurectomy/abrasion reduces recurrence to <5% versus chemical pleurodesis alone (recurrence 10-20%).