Synopsis
Diagnose primary spontaneous pneumothorax, identify high-risk features and choose conservative, ambulatory or invasive management according to symptoms, physiology, safety and patient preference.
- PSP means spontaneous pleural air without known clinically apparent underlying lung disease; actively look for secondary disease rather than assuming it from age or body habitus alone.
- Confirm a stable suspected pneumothorax with chest radiography and use thoracic ultrasound/CT when needed; tension physiology is a clinical diagnosis and imaging must not delay decompression.
- BTS 2023 makes symptoms and physiological risk—not size alone—the main acute-management decision.
Key red flags
Severe distress, hypotension, tachycardia, cyanosis, altered consciousness, raised JVP or peri-arrest deterioration with unilateral reduced breath sounds; tracheal deviation is late and absence does not reassure.
Investigation priorities
Confirm pleural air, laterality and approximate extent in a stable patient.
Management branches
Asymptomatic or minimally symptomatic PSP with no significant pain/breathlessness, no physiological compromise and reliable follow-up.
- Confirm diagnosis in a stable patient, assess all high-risk characteristics and provide appropriate analgesia; discuss that size alone does not mandate intervention.
- Observe long enough to establish clinical stability and safe mobilisation; supply written red flags and a direct route back for increasing pain, breathlessness, dizziness or syncope.
Symptomatic PSP without instability where ambulatory expertise/device pathway, support and follow-up are available.
Key medicines
Paracetamol1 g orally every 4–6 hours as needed, maximum 4 g in 24 hours for a typical adult; use a lower maximum in body weight below 50 kg, liver disease, malnutrition or heavy alcohol use.
Ibuprofen200–400 mg orally up to three times daily with food for the shortest necessary course when an NSAID is appropriate.