INTRODUCTION
Gas in the pleural space is termed pneumothorax. Pneumothorax can be a life-threatening condition that needs prompt attention. The management strategies of primary spontaneous pneumothorax (PSP; presents in the absence of an external factor/underlying cause) and secondary spontaneous pneumothorax (SSP; presents as a complication of underlying lung disease) (table 1) differ in their management strategies.The management of PSP is discussed in this topic review. The etiology and diagnosis of pneumothorax and the management of SSP are discussed separately. (See "Pneumothorax in adults: Epidemiology and etiology" and "Clinical presentation and diagnosis of pneumothorax" and "Treatment of secondary spontaneous pneumothorax in adults".)
INITIAL EVALUATION AND MANAGEMENT
General principles — Following the radiographic identification of PSP, clinicians should quickly estimate the stability of the patient and the symptom burden so that appropriate therapy can be initiated. The principle focus of PSP management is to relieve symptoms and stop the air leak rather than rapidly expanding the lung to achieve radiographic resolution (ie, "treating the chest radiograph"), which does not necessarily stop the air leak. The assessment of size, while reasonable, is now less important in determining a treatment strategy. Size assessment is discussed separately. (See "Clinical presentation and diagnosis of pneumothorax", section on 'Pneumothorax size'.)
The approach to managing PSP varies widely among institutions and across continents. Our approach expands upon that outlined in several published clinical consensus statements and guidelines from the American College of Chest Physicians (ACCP; 2001), the British Thoracic Society (BTS; 2023), the European Respiratory Society (2015), and the Japanese Association for Chest Surgery (2014) [1-4]. Our approach is one that prioritizes patient safety and symptom control, preferably with minimal intervention, to avoid associated pain and risks.
Symptom control — All patients with PSP should receive resuscitation with a focus on airway stabilization (if needed), supplemental oxygen to treat hypoxemia (if present), and the provision of adequate analgesia (if indicated). PSP is rarely life-threatening, and the associated breathlessness is typically mild, often only affecting severe exertion; some patients may also experience pain. The clinical features of pneumothorax are described separately. (See "Clinical presentation and diagnosis of pneumothorax", section on 'Clinical presentation'.)