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pulm.pneumothorax.core.v1

Pneumothorax (PSP / SSP / tension / traumatic)

pulmonologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Deep-deepening pass 2026-05-16 (content-factory/pulmonary.md rank 8): corrected the evidence block (previously held IMPACT/ProMISe/POINT/REDUCE — COPD/sepsis trials, NOT pneumothorax) to 7 PubMed-verified PTX PMIDs with DOIs and inline effect sizes. Effect-size anchors encoded: Brown 2020 (94.4% conservative radiographic resolution by 8 wk; ~85% intervention-avoided; 12-mo recurrence 8.8% conservative vs 16.8% interventional); RAMPP 2020 (median LOS 0 vs 6 days with ambulatory device); Cochrane/Noppen aspiration immediate success ~50–70% / ~59%; ~30% recurrence after first untreated PSP vs <5% after surgical pleurodesis (ERS/ESTS 2024); smoking ~9–22× lifetime PSP risk. Drainage ladder captured stepwise (tension-emergency / small-PSP-observe / large-PSP-aspiration / pigtail-RAMPP-ambulatory / large-bore-SSP-traumatic / VATS-recurrence); second pharmacologic axis adds O2-resorption (3–4× rate, with CO2-retainer caution), multimodal analgesia, pleurodesis agents (graded talc, autologous blood patch), and smoking-cessation recurrence prevention. Differential/Bayesian partition encoded as triggers: MECE etiology classes (PSP/SSP/tension/traumatic/iatrogenic/catamenial/genetic/HIV-PJP/pregnancy) + time-critical look-alike pivots (tension PTX vs massive PE vs tamponade via POCUS lung sliding + cardiac views; PTX vs giant bulla via CT). Cross-dossier wiring: workups.branches_to → pulm.pe.core.v1, cardio.cardiac-tamponade.core.v1, pulm.copd.core.v1, pulm.idiopathic_pulmonary_fibrosis.v1, symptom.chest_pain.ed_undifferentiated.v1; sibling_differentiation with pulm.pleural-effusion.core.v1, pulm.pe.core.v1, pulm.copd.core.v1, pulm.idiopathic_pulmonary_fibrosis.v1. Special populations covered as triggers: COPD/SSP (low intervention threshold), pregnancy (US-first, deferred VATS, modified delivery), mechanically-ventilated (emergent large-bore — life_threatening), HIV/PJP (SSP behaviour + concurrent PJP Rx), catamenial/endometriosis (gyn + diaphragm surgery + hormonal), Marfan/BHD (genetics + family screening + earlier pleurodesis). Per-setting playbooks (ED / inpatient / ICU) include needle decompression sites, ambulatory Heimlich pathway, surgical referral timing (5 d air leak), ventilator-strategy barotrauma limits. PRODUCTION blockers (unchanged scope — registry/manifest out of dossier-edit scope): (1) RxCUIs carried over from prior author, not re-run through scripts/research/rxnav-validate.ts this pass — no NEW hand-authored RxCUIs added; (2) BTS PTX size estimator + air-leak quantification not yet in clinical-tools-registry; (3) no engine-specific test file under tests/ (uses shared dossier-contract.test.ts). See _briefs/pulm.pneumothorax.core.v1.depth.md for schema-gap log.

Entry points (4)

  • symptom
    Sudden pleuritic chest pain ± dyspnea
    sudden_pleuritic_pain
  • imaging
    Pneumothorax on CXR / lung ultrasound (loss of lung sliding) / CT
    pneumothorax_on_imaging
  • vital_abnormality
    Tension features — hypotension, tracheal deviation, distended neck veins
    tension_signs
  • problem_list
    COPD/CF/Marfan/recent procedure/chest trauma raising index of suspicion
    lung_disease_or_trauma

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    PSP (tall thin young) vs SSP (older with COPD) phenotype
  • sex
    demographic • used at CONTEXT
    PSP male predominance + catamenial PTX in females
  • sbprequired
    vital • used at CONTEXT
    Hypotension flags tension PTX
  • hrrequired
    vital • used at CONTEXT
    Tachycardia in tension/large PTX
  • spo2required
    vital • used at CONTEXT
    Severity of impairment + drainage threshold
  • rrrequired
    vital • used at CONTEXT
    Tachypnea + work-of-breathing severity
  • underlying_lung_diseaserequired
    history • used at CONTEXT
    Distinguishes PSP from SSP (COPD, CF, ILD, lung cancer)
  • trauma_or_recent_procedurerequired
    history • used at CONTEXT
    Iatrogenic vs traumatic — drives chest tube indication
  • mechanical_ventilation
    history • used at CONTEXT
    Vent-associated PTX requires chest tube
  • anticoagulation
    history • used at CONTEXT
    Bleeding risk for procedure planning
  • cxr_uprightrequired
    imaging • used at INITIAL_WORKUP
    Upright PA CXR for size estimation
  • lung_ultrasound
    imaging • used at INITIAL_WORKUP
    Bedside diagnosis (loss of sliding, lung point)
  • ct_chest
    imaging • used at BRANCHING_WORKUP
    Occult PTX, blebs/bullae mapping, surgical planning

12-phase flow (12)

  1. 1FRAME
    Confirm pneumothorax type — primary spontaneous (PSP) vs secondary spontaneous (SSP) vs tension vs traumatic vs iatrogenic vs catamenial
    inputs: underlying_lung_disease, trauma_or_recent_procedure
    advance: Type/etiology classified
  2. 2ENTRY
    Triggered by sudden chest pain, imaging finding, or trauma
    inputs: age
    advance: Entry trigger captured
  3. 3CONTEXT
    Smoking, height/build, family history, prior PTX, mechanical ventilation status, anticoag, allergies
    inputs: sbp, hr, spo2, rr, underlying_lung_disease, trauma_or_recent_procedure, mechanical_ventilation, anticoagulation
    advance: Substrate captured
  4. 4RED_FLAGS
    Tension PTX → immediate needle decompression (4–5th ICS anterior axillary or 2nd ICS MCL) + chest tube; hemopneumothorax with shock; bilateral PTX
    inputs: sbp
    advance: Tension excluded or decompressed
  5. 5INITIAL_WORKUP
    Upright CXR (PA) for size; bedside lung US in unstable patient; ABG in SSP/respiratory failure
    inputs: cxr_upright, lung_ultrasound
    actions: pneumothorax
    advance: Size + side + tension status documented
  6. 6BRANCHING_WORKUP
    CT chest for bleb/bulla mapping in recurrent PSP, SSP, or traumatic; HRCT for ILD substrate; pregnancy test if catamenial suspicion
    inputs: ct_chest
    advance: Substrate clarified
  7. 7DIFFERENTIAL
    PSP vs SSP vs tension vs traumatic vs iatrogenic vs catamenial; consider PE / MI / pneumonia / aortic dissection
    advance: PTX type assigned and life-threatening alternatives excluded
  8. 8RISK_STRATIFICATION
    BTS 2023 size + symptom assessment; minimally symptomatic PSP eligible for conservative management (PSP Trial); ambulatory candidacy via 8F + Heimlich (RAMPP)
    advance: Management strategy stratified
  9. 9TREATMENT
    PSP minimally symptomatic → conservative observation (PSP Trial 2020); PSP large/symptomatic → needle aspiration first-line (Bintcliffe 2015); SSP → chest drain. Tension → needle decompression then chest tube. Traumatic → chest tube. Recurrent → VATS pleurodesis/bullectomy (ERS/ESTS 2024). High-flow O2 to accelerate resorption.
    inputs: spo2
    advance: Drainage strategy + admission/observation plan in place
  10. 10DISPOSITION
    Outpatient observation for small PSP (with safety-net + 24h CXR); admit for chest tube; ICU for tension/SSP with respiratory failure; surgical referral for second ipsilateral or first contralateral PTX
    advance: Disposition set
  11. 11MONITORING
    Serial CXR / US, drain output and air leak trend, pain control, smoking cessation counselling; aviation/diving counselling pre-discharge
    advance: Resolution documented and recurrence-prevention plan in place
  12. 12FOLLOWUP
    CXR at 2–4 weeks; aviation 1 week post-resolution; absolute lifelong contraindication to scuba diving (BTS); smoking cessation; surgical referral if recurrent; advise re: future PTX symptoms
    advance: Recurrence-prevention plan + surgical consultation completed if criteria met