Clinical Commander

Back to dossier
pulm.pneumothorax.core.v1PRODUCTION
pulm.pneumothorax.core.v1

Pneumothorax (PSP / SSP / tension / traumatic)

pulmonologyacuteadult
Hard-required inputs
0 / 8
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm pneumothorax type — primary spontaneous (PSP) vs secondary spontaneous (SSP) vs tension vs traumatic vs iatrogenic vs catamenial

Inputs
2
Actions
0
Advance rule
Set
Advance when

Type/etiology classified

Patient inputs (13)

PSP (tall thin young) vs SSP (older with COPD) phenotype

Hypotension flags tension PTX

Tachycardia in tension/large PTX

Severity of impairment + drainage threshold

Tachypnea + work-of-breathing severity

Distinguishes PSP from SSP (COPD, CF, ILD, lung cancer)

Iatrogenic vs traumatic — drives chest tube indication

Upright PA CXR for size estimation

Occult PTX, blebs/bullae mapping, surgical planning

PSP male predominance + catamenial PTX in females

Vent-associated PTX requires chest tube

Bleeding risk for procedure planning

Bedside diagnosis (loss of sliding, lung point)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (14)

14 need judgement
  • informationallife_threateningtension_pneumothorax
    Hypotension + dyspnea + decreased breath sounds + tracheal deviation OR ventilated patient with sudden decompensation + raised airway pressures (ATLS 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghemopneumothorax_or_traumatic
    Hemopneumothorax with hemodynamic compromise OR penetrating chest trauma (ATLS 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmechanically_ventilated_PTX
    Pneumothorax in mechanically ventilated patient — barotrauma; near-universal progression to tension under positive pressure (ACCP 2001; BTS 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningtension_vs_massive_pe_vs_tamponade_pivot
    Acute dyspnea + shock + ↑JVD: time-critical 3-way pivot. Tension PTX = tracheal deviation AWAY + absent breath sounds + hyperresonance + absent lung sliding/lung point on POCUS. Massive PE = lung sliding present + acute RV dilation/D-sign + clear lungs. Tamponade = muffled heart sounds + pulsus paradoxus + pericardial effusion with RV diastolic collapse on POCUS (ATLS 2018; ESC 2019 PE; ESC 2015 pericardial)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresecondary_spontaneous_pneumothorax_any_size
    Pneumothorax in patient with underlying lung disease (COPD, ILD, CF, lung cancer, prior TB) (BTS 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_or_bilateral_PTX
    Second ipsilateral PTX, first contralateral PTX, or bilateral PTX (BTS 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehiv_pjp_associated_ptx
    Spontaneous PTX in HIV with low CD4 — Pneumocystis jirovecii pneumonia with subpleural cysts/pneumatoceles is the classic substrate (BTS 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_associated_ptx
    Spontaneous PTX during pregnancy or labour (Valsalva) — maternal hypoxia threatens fetus; ionising-radiation minimisation required (BTS 2023; ERS/ESTS 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatelarge_or_symptomatic_PSP
    PSP ≥2 cm at hilum on CXR OR significant symptoms despite small size (BTS 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepersistent_air_leak_5_days
    Continuous bubbling on water seal for ≥5 days (BTS 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateptx_vs_giant_bulla_pivot
    Apical lucency without lung markings in severe emphysema — PTX (pleural line convex to chest wall, follows ribs) vs giant bulla (concave inner margin, septa). CT chest is the mandatory pivot before drainage (BTS 2023; GOLD 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateiatrogenic_pneumothorax
    PTX after a procedure — transthoracic/transbronchial lung biopsy, CVC insertion, thoracentesis, pacemaker, mechanical ventilation, acupuncture (BTS 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecatamenial_or_endometriosis_associated
    Recurrent right-sided PTX in a menstruating woman, onset within 72 h of menses, ± known pelvic endometriosis or diaphragmatic fenestrations (BTS 2023; ERS/ESTS 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategenetic_substrate_marfan_bhd_recurrent
    PSP with Marfan/Loeys-Dietz habitus, Birt-Hogg-Dubé (fibrofolliculomas + renal tumours + basal cysts), or strong family history of PTX (BTS 2023; ERS/ESTS 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RED_FLAGSoptionalDrives severity classification
Loading…

Recommended regimen

BTS 2023 + ERS/ESTS 2024 — drainage strategy by type, size, symptoms
axis: pneumothorax_drainage_ladderstep tension_emergency - Tension pneumothorax — emergent decompression
Selected step "Tension pneumothorax — emergent decompression" — Hypotension + dyspnea + decreased breath sounds + tracheal deviation OR vent-associated rapid decompensation
  • oxygen
    first line
    oxygen
    High-flow O2 15 L/min via NRB • inhaled • continuous
    triggers: tension_PTX, any_PTX
    Accelerates resorption (4× rate vs RA) and treats hypoxia
    rxcui 7806

ed playbook — drug actions (5)

  1. 1. oxygen
    High-flow 10–15 L/min NRB • inhaled • continuous
    trigger: Any pneumothorax
    Accelerates pleural air absorption (4× vs RA); also treats hypoxia
  2. 2. acetaminophen + ibuprofen
    APAP 1 g + ibuprofen 400 mg • PO/IV • q6h scheduled
    trigger: Pain
    Multimodal analgesia
  3. 3. lidocaine local + procedural sedation (fentanyl + midazolam)
    Lido 1% 10–20 mL; fent 50–100 µg + midaz 1–2 mg IV • SC + IV • pre-procedure
    trigger: Aspiration / chest tube
    Procedural anesthesia + sedation; capnography
  4. 4. cefazolin
    2 g IV × 1 • IV • single dose
    trigger: Traumatic chest tube
    EAST trauma single-dose prophylaxis
  5. 5. oxycodone (rescue)
    5 mg PO q4h PRN • PO • q4h PRN
    trigger: Breakthrough pain
    Limit duration

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Sudden pleuritic chest pain ± dyspnea; Pneumothorax on CXR / lung ultrasound (loss of lung sliding) / CT; Tension features — hypotension, tracheal deviation, distended neck veins.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pneumothorax (PSP / SSP / tension / traumatic)** (pulm.pneumothorax.core.v1).
Phenotype framing: PSP vs SSP vs tension vs traumatic vs iatrogenic vs catamenial; consider PE / MI / pneumonia / aortic dissection
Scope: Confirm pneumothorax type — primary spontaneous (PSP) vs secondary spontaneous (SSP) vs tension vs traumatic vs iatrogenic vs catamenial

No severity triggers fired against current inputs.

Plan

Regimen axis: **BTS 2023 + ERS/ESTS 2024 — drainage strategy by type, size, symptoms** — step "Tension pneumothorax — emergent decompression".
1. oxygen High-flow O2 15 L/min via NRB inhaled continuous (oxygen, first line) — Accelerates resorption (4× rate vs RA) and treats hypoxia

Setting playbook (ed) — Identify and decompress tension PTX, classify type/size, choose drainage modality (observe / aspirate / pigtail / large-bore), arrange disposition
2. oxygen High-flow 10–15 L/min NRB inhaled continuous — Any pneumothorax (Accelerates pleural air absorption (4× vs RA); also treats hypoxia)
3. acetaminophen + ibuprofen APAP 1 g + ibuprofen 400 mg PO/IV q6h scheduled — Pain (Multimodal analgesia)
4. lidocaine local + procedural sedation (fentanyl + midazolam) Lido 1% 10–20 mL; fent 50–100 µg + midaz 1–2 mg IV SC + IV pre-procedure — Aspiration / chest tube (Procedural anesthesia + sedation; capnography)
5. cefazolin 2 g IV × 1 IV single dose — Traumatic chest tube (EAST trauma single-dose prophylaxis)
6. oxycodone (rescue) 5 mg PO q4h PRN PO q4h PRN — Breakthrough pain (Limit duration)

Non-pharmacologic actions:
- Tension PTX → immediate needle decompression: 4–5th ICS anterior axillary line OR 2nd ICS midclavicular (adult finger thoracostomy alternative); follow with chest tube
- Aspiration: 14–16 G IV cannula 2nd ICS MCL or 4–5th ICS AAL; aspirate up to 2.5 L
- Pigtail / small-bore chest tube (8–14 Fr) under US guidance — ambulatory candidacy if PSP no air leak
- Large-bore chest tube (24–28 Fr) for SSP / hemopneumothorax / vent-associated
- Lung ultrasound for diagnosis when unstable
- Avoid positive-pressure ventilation if at all possible until decompressed

AVOID / contraindication checks:
- NSAID avoid if AKI GI bleed or recent anastomosis (BTS 2023)
- Opioid minimise duration screen for OUD (ACCP 2001)
- Procedural sedation capnography required (BTS 2023)
- Talc use graded only avoid ungraded ARDS risk (ERS/ESTS 2024)
- Scuba diving lifetime contraindication unless bilateral surgical pleurectomy (BTS 2023 Roberts)
- High flow oxygen titrate to 88 92% if COPD CO2 retainer SSP (Austin 2010; BTS 2023)
- Do not observe or aspirate a ventilated or tension PTX go straight to chest tube (BTS 2023)

Monitoring

Regimen monitoring:
- serial CXR every 6 to 24h until resolved (BTS 2023)
- air leak assessment q shift (BTS 2023)
- pain score q shift (BTS 2023)
- drain output q shift (BTS 2023)
- aspirate volume documented at aspiration max 2.5 L (BTS 2023)
- CXR at 2 to 4 weeks post discharge (BTS 2023 Roberts)
- aviation advice no flight for 1 week post resolution (BTS 2023)
- lifetime diving contraindication documented (BTS 2023)

Setting (ed) monitoring:
- Serial CXR or US q4-6 h initially then daily (BTS 2023)
- Pulse oximetry continuous (BTS 2023)
- Air leak (bubbling) assessment at chest drain (BTS 2023)
- Drain output trend (BTS 2023)

Follow-up plan: 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
- Close-out criterion: Recurrence-prevention plan + surgical consultation completed if criteria met

Monitoring phase: Serial CXR / US, drain output and air leak trend, pain control, smoking cessation counselling; aviation/diving counselling pre-discharge

Disposition

Current setting: ed — Identify and decompress tension PTX, classify type/size, choose drainage modality (observe / aspirate / pigtail / large-bore), arrange disposition

Disposition criteria:
- Discharge with safety-net (PSP Trial pathway Brown 2020): minimally symptomatic small PSP, social support, can return for 24-h CXR, return precautions reviewed
- Ambulatory pigtail (RAMPP pathway Hallifax 2020): PSP, no air leak after pigtail placement, Heimlich valve, follow-up in 2-7 d
- Admit ward: requires chest tube + observation (BTS 2023)
- Admit ICU: SSP with respiratory failure, vent-associated PTX, hemopneumothorax (BTS 2023)

Escalation triggers (move to higher acuity):
- Recurrent tension despite needle decompression → finger thoracostomy + larger tube (ATLS 2018)
- SSP with respiratory failure → ICU + chest tube (BTS 2023)
- Bilateral PTX → urgent surgical referral (ERS/ESTS 2024)
- Hemopneumothorax with shock → trauma activation (ATLS 2018)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Hypotension + dyspnea + decreased breath sounds + tracheal deviation OR ventilated patient with sudden decompensation + raised airway pressures (ATLS 2018)
- [LIFE_THREATENING] Hemopneumothorax with hemodynamic compromise OR penetrating chest trauma (ATLS 2018)
- [LIFE_THREATENING] Pneumothorax in mechanically ventilated patient — barotrauma; near-universal progression to tension under positive pressure (ACCP 2001; BTS 2023)

Citations

- BTS 2023 Guideline for Pleural Disease (Roberts, Thorax 2023) + Joint ERS/EACTS/ESTS 2024 spontaneous pneumothorax CPG + Brown PSP RCT (NEJM 2020) + Hallifax RAMPP RCT (Lancet 2020) + Cochrane aspiration-vs-drain + ATLS 10th [PMID:37553157](https://pubmed.ncbi.nlm.nih.gov/37553157/)
- Cited evidence (PMID 38804185) [PMID:38804185](https://pubmed.ncbi.nlm.nih.gov/38804185/)
- Cited evidence (PMID 31995686) [PMID:31995686](https://pubmed.ncbi.nlm.nih.gov/31995686/)
- Cited evidence (PMID 32622394) [PMID:32622394](https://pubmed.ncbi.nlm.nih.gov/32622394/)
- Cited evidence (PMID 28881006) [PMID:28881006](https://pubmed.ncbi.nlm.nih.gov/28881006/)

Last reconciled with current guidelines: 2026-05-16.
References
  • BTS 2023 Guideline for Pleural Disease (Roberts, Thorax 2023) + Joint ERS/EACTS/ESTS 2024 spontaneous pneumothorax CPG + Brown PSP RCT (NEJM 2020) + Hallifax RAMPP RCT (Lancet 2020) + Cochrane aspiration-vs-drain + ATLS 10th — PMID:37553157
  • Cited evidence (PMID 38804185) — PMID:38804185
  • Cited evidence (PMID 31995686) — PMID:31995686
  • Cited evidence (PMID 32622394) — PMID:32622394
  • Cited evidence (PMID 28881006) — PMID:28881006