Acute management for spontaneous pneumothorax

• Conservative management can be considered for the treatment of minimally symptomatic (ie, no significant pain or breathlessness and no physiological compromise) or asymptomatic primary spontaneous pneumothorax in adults regardless of size. (Conditional—by consensus)
• Ambulatory management should be considered for the initial treatment of primary spontaneous pneumothorax (PSP) in adults with good support, and in centres with available expertise and follow-up facilities. (Conditional)
• In patients not deemed suitable for conservative or ambulatory management, needle aspiration or tube drainage should be considered for the initial treatment of primary spontaneous pneumothorax in adults. (Conditional)
• Chemical pleurodesis can be considered for the prevention of recurrent of secondary spontaneous pneumothorax (SSP) in adults (eg, patients with severe chronic obstructive pulmonary disease who significantly decompensated in the presence of a pneumothorax, even during/after the first episode). (Conditional)
• Thoracic surgery can be considered for the treatment of pneumothorax in adults at initial presentation if recurrence prevention is deemed important (eg, patients presenting with tension pneumothorax, or those in high-risk occupations). (Conditional)

Good practice points

• When establishing local ambulatory treatment pathways, planning and coordination between with the emergency department, general medicine and respiratory medicine is vital.
• When performing chemical pleurodesis for the treatment of pneumothorax in adults, adequate analgesia should be provided before and after treatment.
• All treatment options should be discussed with the patient to determine their main priority, with consideration for the least invasive option.

Optimal management after the resolution of a first episode of pneumothorax

• Elective surgery may be considered for patients in whom recurrence prevention is deemed important (eg, at-risk professionals (divers, airline pilots, military personnel), or those who developed a tension pneumothorax at first episode).
• Elective surgery should be considered for patients with a second ipsilateral or first contralateral pneumothorax.
• Discharge and activity advice should be given to all patients post pneumothorax.

Scope of the guideline

The guideline is specifically designed to answer important questions in the investigation and management of pleural disease in adults. Questions have been agreed by the whole guideline group. While as many important questions as possible have been included, there are areas that have not been covered. As this guideline covers four broad areas of pleural disease, the number of questions is limited by the practicalities of writing a guideline with a large scope that remains relevant and up to date at the point of publication and a workload manageable by the guideline group.

Areas not covered by the guideline

Mesothelioma has been excluded from this guideline as this is already covered in the BTS Guideline for the investigation and management of pleural mesothelioma.10 Benign (non-infectious, non-pneumothorax) pleural disease and rare pleural diseases are also excluded. Guidance on pleural interventions are covered in the BTS Clinical Statement on Pleural Procedures.