Eduovisual
Respiratory
Tension pneumothorax: bedside recognition and decompression
— Air enters pleura during inspiration but cannot exit during expiration
— Rising intrapleural pressure compresses ipsilateral lung, then shifts mediastinum, kinks SVC/IVC, drops preload
— End result: hypoxemia + hypotension + cardiac arrest if untreated
— Blunt or penetrating chest trauma (rib fractures, stab/gunshot wounds)
— Mechanically ventilated patients with sudden hypoxia, rising peak airway pressures, hypotension
— Post-procedural: central line placement (subclavian/IJ), thoracentesis, transbronchial biopsy, pacemaker insertion
— CPR with bag-valve-mask ventilation
— COPD/asthma exacerbation with barotrauma; necrotizing pneumonia; ruptured bleb in tall, thin young men (spontaneous progressing to tension)
— Delay to decompression
— Misattribution to PE, cardiac tamponade, or MI in undifferentiated shock
— Failed needle decompression due to inadequate catheter length in obese/muscular patients
Board pearl: If a ventilated ICU patient suddenly drops BP and SpO₂ with unilaterally absent breath sounds and tracheal deviation away from the affected side, the next step is immediate needle or finger thoracostomy — not a portable CXR, not CT, not a fluid bolus. Confirmation imaging follows decompression.
CCS pearl: On CCS, ordering "chest tube thoracostomy" or "needle decompression, left chest" advances the clock far better than serial imaging when vitals are deteriorating.
— Penetrating chest wound, especially between nipples and umbilicus (think "box" injuries — cardiac + lung)
— Blunt deceleration (MVC, fall from height) with chest wall tenderness
— Recent rib fracture, particularly with positive-pressure ventilation
— "Patient developed acute hypoxia 30 minutes after subclavian central line placement" → pneumothorax until proven otherwise; if hypotensive → tension
— Post-thoracentesis dyspnea
— Post-transbronchial biopsy chest pain
— New intubation with high PEEP, especially in ARDS or asthma
— Tall, thin males age 10–30, often smokers, with apical subpleural blebs
— Marfan, Ehlers-Danlos, homocystinuria associations
— COPD (most common), cystic fibrosis, TB, PCP pneumonia in HIV, lymphangioleiomyomatosis (LAM) in women of reproductive age, Birt-Hogg-Dubé, catamenial pneumothorax (within 72h of menses)
— Sudden rise in peak inspiratory pressure with stable plateau pressure differential
— Loss of tidal volume on volume-control; loss of pressure on pressure-control
— Ventilator high-pressure alarms
Key distinction: Simple pneumothorax = unilateral pleuritic pain, mild dyspnea, stable vitals. Tension pneumothorax = same findings PLUS hemodynamic compromise (hypotension, JVD, AMS). The shift from simple → tension is the inflection point that mandates immediate decompression rather than tube thoracostomy planning.
Board pearl: Catamenial pneumothorax in a woman with cyclical right-sided chest pain → think thoracic endometriosis; recurrent and usually right-sided.
— Unilateral absent or markedly diminished breath sounds
— Hyperresonance to percussion on the affected side
— Tracheal deviation away from the affected side (late finding)
— Distended neck veins (JVD) from impaired venous return
— Hypotension with narrow pulse pressure
— Tachycardia, often >120
— Cool, clammy extremities, delayed capillary refill
— Pulsus paradoxus may be present
— Late: bradycardia, PEA arrest
— Severe tachypnea, accessory muscle use, tripoding
— Hypoxia despite high FiO₂
— Subcutaneous emphysema — crepitus over chest wall, neck, face ("Rice Krispies"); supports diagnosis but not required
— Asymmetric chest wall expansion (affected side lags)
— Trachea deviated away from affected side
— PMI displaced
— Heart sounds shifted or muffled
— JVD may be exaggerated by PEEP
— Tracheal deviation hard to assess if intubated and taped
— Best clue is sudden rise in peak airway pressure with hypotension
— Obese or muscular patients: breath sounds difficult to localize
— Bilateral disease (COPD): hyperresonance may be baseline
— Trauma bay noise often masks auscultation — rely on percussion and visual chest rise
Step 3 management: When exam suggests tension pneumothorax in an unstable patient, the single best next step is immediate needle decompression (or finger thoracostomy if trained) followed by tube thoracostomy. Do not delay for imaging.
Board pearl: Tracheal deviation and JVD are late, ominous signs — their absence does NOT rule out tension pneumothorax. Hypoxia + hypotension + unilateral absent breath sounds is sufficient to act.
— Fastest, most sensitive modality (>90% sensitivity vs ~50% for supine CXR)
— Loss of lung sliding on M-mode → "barcode" or "stratosphere sign" replaces normal "seashore sign"
— Absence of B-lines and comet-tail artifacts
— Lung point — transition between sliding and no-sliding lung; 100% specific
— Pearls: rule out with sliding present; bullous emphysema and prior pleurodesis cause false positives for absent sliding
— Visceral pleural line with absent lung markings peripherally
— Deep sulcus sign on supine film (lateral costophrenic angle abnormally deep and lucent)
— Mediastinal shift, depressed hemidiaphragm, widened intercostal spaces suggest tension
— Subcutaneous emphysema visible as soft-tissue lucencies
— Gold standard for size, occult pneumothorax, underlying parenchymal disease
— Never the first study in suspected tension — reserved for stable patients or post-decompression assessment
— Hypoxemia, respiratory alkalosis early; mixed acidosis if shock progresses
— Lactate elevated in obstructive shock
Key distinction: Supine CXR is insensitive for pneumothorax (the air rises anteriorly creating a deep sulcus, not a clear visceral line). In trauma resuscitation where patients are flat, POCUS beats CXR for detection.
CCS pearl: Don't waste clock time on CT for an unstable patient with suspected tension pneumothorax. Order chest tube, then portable CXR for post-procedure confirmation.
— Portable upright chest X-ray after needle/tube placement to confirm lung re-expansion and tube position
— Look for residual pneumothorax, hemothorax, tube kinking, or intraparenchymal placement
— Repeat in 6–12 hours and after suction adjustment
— Quantifies pneumothorax volume, identifies underlying bullae, blebs, parenchymal disease
— Detects occult pneumothorax in 2–10% of trauma CTs missed on CXR
— Plans for VATS/bullectomy in recurrent disease
— BTS: small <2 cm, large ≥2 cm from chest wall at level of hilum on CXR
— ACCP: small <3 cm apex-to-cupola distance, large ≥3 cm
— Tension is independent of size — physiology trumps measurement
— Continuous bubbling in water-seal chamber → ongoing bronchopleural communication
— Persistent leak >5 days suggests bronchopleural fistula → CT and pulmonology/thoracic surgery consult
— Hemopneumothorax: ultrasound shows pleural fluid + absent sliding; large-bore chest tube (28–32 Fr) needed
— Tension pneumomediastinum: rare; CT confirms; consider Boerhaave/tracheobronchial injury
— Catamenial pneumothorax workup: thoracic MRI, diagnostic VATS for endometrial implants
— High-resolution CT for blebs/bullae, LAM, Birt-Hogg-Dubé
— α1-antitrypsin level in young COPD patients
— HIV testing in PCP-associated pneumothorax
Board pearl: A persistent air leak >5 days after tube thoracostomy is an indication for VATS with bleb resection and pleurodesis — high-yield Step 3 surgical referral question.
Step 3 management: Order post-tube CXR, repeat at 24h, then daily until water seal trial; document air leak status each shift.
— Unstable (hypotension, hypoxia, altered mental status, impending arrest): → immediate needle decompression or finger thoracostomy, then chest tube
— Stable with large or symptomatic pneumothorax: → tube thoracostomy (small-bore pigtail 8–14 Fr often adequate)
— Stable, small (<2–3 cm), minimally symptomatic primary spontaneous: → observation with high-flow O₂, repeat CXR in 4–6h
— Stable secondary spontaneous (COPD, etc.): → admit, lower threshold for chest tube even if small
— High-flow O₂ (non-rebreather 10–15 L/min) accelerates pleural air resorption ~4-fold by creating nitrogen gradient
— Useful adjunct in observation and post-tube management
— Primary survey "B" → if absent breath sounds + hypotension → immediate decompression
— Do not wait for CXR in primary survey
— Finger thoracostomy increasingly favored over needle decompression in pre-hospital and trauma bay settings
— Often small and self-limited
— Tube needed if symptomatic, enlarging, or in ventilated patient
— Primary spontaneous: ~30% after first episode, 50% after second
— Indications for definitive surgery (VATS/pleurodesis): second ipsilateral episode, first contralateral, bilateral, persistent leak, high-risk profession (pilot, diver)
Key distinction: Stable simple pneumothorax = chest tube or observation. Unstable = decompress NOW. Confusing these two is the most common Step 3 distractor.
CCS pearl: When you advance the clock after chest tube, reassess vitals, breath sounds, and order CXR — don't just walk away.
— High-flow O₂ via non-rebreather at 10–15 L/min
— Increases pleural air absorption rate (~1.25%/day → ~4–5%/day)
— Continue until pneumothorax resolved or chest tube placed
— Local infiltration: 1% lidocaine up to 4.5 mg/kg (max 300 mg) — infiltrate skin, subcutaneous tissue, periosteum of rib, and parietal pleura (most painful step)
— Procedural sedation if needed: fentanyl 0.5–1 mcg/kg IV + midazolam 0.02–0.05 mg/kg IV, or ketamine 0.5–1 mg/kg IV
— Avoid heavy sedation in hemodynamically unstable patients — ketamine preferred for hypotensive patients
— Trauma patients: single dose of first-generation cephalosporin (cefazolin 2 g IV) before insertion reduces empyema risk
— Routine prophylaxis for iatrogenic/spontaneous pneumothorax tubes is NOT supported
— IV crystalloid bolus while preparing decompression — limited benefit until air evacuated, but bridges venous return
— Vasopressors (norepinephrine) only if hypotension persists after decompression — should rarely be needed
— Acetaminophen ± short course NSAIDs for pleuritic pain (NSAIDs caution in renal dysfunction, elderly)
— Avoid opioids beyond a few days
— Smoking cessation counseling + pharmacotherapy (varenicline, nicotine replacement, bupropion) — smoking is a major recurrence risk
Board pearl: Nitrous oxide is contraindicated in any patient with known or suspected pneumothorax — it diffuses into closed gas spaces and rapidly expands the pneumothorax. High-yield anesthesia question.
Step 3 management: Order cefazolin 2 g IV pre-procedure for traumatic chest tube; not routinely for spontaneous pneumothorax tubes.
— Site (updated ATLS): 5th intercostal space, anterior axillary line (preferred in adults) OR 2nd ICS midclavicular line — adult chest wall thickness often exceeds 5-cm needle length at the 2nd ICS
— Use 14-gauge, ≥8-cm angiocatheter
— Insert over the top of the rib (avoid neurovascular bundle running below each rib)
— Listen/feel for rush of air; leave catheter in place until tube thoracostomy
— Success confirmed by hemodynamic improvement and improved oxygenation
— Increasingly preferred in trauma; bypasses needle-length failures
— Skin incision at 5th ICS anterior axillary line → blunt dissection through intercostals → finger sweep into pleural space
— Site: "triangle of safety" — anterior to mid-axillary line, lateral to pectoralis major edge, above 5th ICS, below axillary apex
— Size: 28–32 Fr for hemothorax/trauma; 14–22 Fr for simple pneumothorax; pigtail 8–14 Fr acceptable for stable spontaneous pneumothorax
— Technique: incise, blunt dissect over rib, finger sweep, insert tube directed apically/posteriorly, connect to underwater seal ± 20 cm H₂O suction, secure with suture
— Confirm with post-procedure CXR
— Bleeding (intercostal artery laceration — more common in elderly with tortuous vessels)
— Lung laceration, diaphragmatic/intra-abdominal injury
— Re-expansion pulmonary edema (limit initial drainage to <1.5 L if chronic large pneumothorax)
— Tube malposition (subcutaneous, fissural)
— Infection/empyema
— Daily CXR, monitor air leak and output
— Water seal trial when no air leak ×24h and lung re-expanded
— Remove after no leak on water seal + no recurrence on CXR
CCS pearl: Order "chest tube thoracostomy, left," then advance clock 30 minutes; check vitals, CXR, and air leak. If unstable post-tube, suspect malposition, ongoing leak, or hemothorax.
Board pearl: Re-expansion pulmonary edema risk is greatest when lung has been collapsed >72h and large volume is drained rapidly — drain slowly with clamping intervals.
— Higher rates of secondary spontaneous pneumothorax due to underlying COPD, pulmonary fibrosis, malignancy
— Lower physiologic reserve — same-size pneumothorax causes greater hemodynamic compromise
— Chest wall calcification and rigid thorax → procedural difficulty
— Tortuous intercostal arteries course away from the inferior rib margin; bleeding risk higher with chest tube
— Frailer pleural tissue → higher re-expansion edema risk
— Lower threshold for chest tube even in "small" pneumothorax — observation alone often fails
— Ultrasound-guided placement preferred to avoid vessels
— Smaller bore pigtail catheters (8–14 Fr) reduce trauma with similar efficacy for simple pneumothorax
— Aggressive incentive spirometry and early mobilization to prevent atelectasis/pneumonia
— Review anticoagulants/antiplatelets: weigh hold vs continue based on indication; reverse warfarin (INR >1.5) with vitamin K ± 4F-PCC before elective tube; for DOACs use idarucizumab (dabigatran) or andexanet (factor Xa) if life-threatening bleed
— Adjust opioid analgesia (avoid morphine; use fentanyl or hydromorphone reduced doses)
— Limit NSAIDs for pleuritic pain — risk AKI in CKD stage ≥3
— Lidocaine dosing usually unaffected but reduce in advanced CKD
— Contrast CT only if necessary; weigh against renal risk
— Caution with acetaminophen (max 2 g/day in cirrhosis)
— Avoid NSAIDs (variceal bleed and hepatorenal risk)
— Coagulopathy: correct INR with FFP only if active bleed or pre-procedure; vitamin K often ineffective in advanced cirrhosis
— Hepatic hydrothorax can mimic pneumothorax clinically — POCUS clarifies
Step 3 management: In an 80-year-old on apixaban with a moderate spontaneous pneumothorax, hold apixaban, use ultrasound-guided pigtail catheter, monitor for bleeding, and reassess for resumption at 24–48h once stable.
Board pearl: Elderly with new pneumothorax + weight loss → evaluate for underlying malignancy (primary lung cancer or metastatic).
— Rare but high-stakes — physiologic dyspnea may mask presentation
— Diaphragm elevated ~4 cm at term → modify chest tube insertion one to two intercostal spaces higher (3rd–4th ICS) to avoid diaphragmatic/intra-abdominal injury
— Avoid supine positioning (aortocaval compression) — left lateral tilt during resuscitation
— Shield abdomen during CXR; CT avoided unless essential
— Catamenial pneumothorax may worsen during ovulation/menses but pregnancy often improves symptoms; recurrence post-partum common
— LMWH typically continued or bridged based on indication
— Mediastinum more mobile → tension physiology develops faster than in adults
— Needle decompression site: 2nd ICS midclavicular line preferred (chest wall thinner; 5th ICS approach less standardized in children)
— Use smaller catheters: 18–20G needle, 8–12 Fr pigtail for tube thoracostomy
— Neonatal pneumothorax common with meconium aspiration, RDS, ventilation — transillumination of chest can be diagnostic
— Cystic fibrosis adolescents: high recurrence; early VATS pleurodesis often pursued
— Spontaneous and recurrent pneumothorax; aortic dissection coexists
— Aggressive VATS pleurodesis after first event in some centers
— PCP pneumonia classically causes pneumothorax (cystic lung disease) — high recurrence and difficult management
— Treat underlying infection alongside drainage
— High PEEP, barotrauma risk; low tidal-volume strategy (6 mL/kg IBW) reduces incidence
— Tension develops rapidly — sudden hypotension + rising peak pressures = decompress
— Boyle's law: pleural gas expands at altitude/depth → absolute contraindication to flying until fully resolved; diving permanently restricted after spontaneous pneumothorax unless definitive surgery
— Wait at least 1–2 weeks after radiographic resolution before commercial flight
Board pearl: Pediatric tension pneumothorax can present with PEA arrest before adult-style hypotension — anticipate it in ventilated neonates and asthmatics.
Step 3 management: Counsel post-pneumothorax patients to avoid air travel for ≥2 weeks after CXR-confirmed resolution and to permanently avoid SCUBA diving unless surgically managed.
— Obstructive shock, PEA arrest, anoxic brain injury
— Mediastinal shift → contralateral lung compression, worsening hypoxia
— Cardiac arrest within minutes if untreated
— Failure due to inadequate catheter length (obese, muscular patients) — up to 50% failure rate at 2nd ICS in some studies
— Lung laceration if no pneumothorax actually present
— Intercostal vessel injury, hemothorax
— Catheter kinking or dislodgement
— Bleeding: intercostal artery laceration (especially in elderly with tortuous vessels), internal mammary artery if inserted too medially
— Organ injury: lung, diaphragm, liver (right), spleen (left), stomach, heart — minimize by using "triangle of safety" and finger sweep before tube insertion
— Malposition: subcutaneous, fissural, intraparenchymal — may worsen oxygenation
— Re-expansion pulmonary edema: unilateral pulmonary edema after rapid drainage of large chronic effusion/pneumothorax; supportive care, occasional intubation
— Empyema: ~1–2% with prophylaxis, higher without; especially in trauma
— Persistent air leak: >5 days → bronchopleural fistula; consider VATS
— Pneumonia, atelectasis from immobility and splinting
— Recurrence: primary spontaneous ~30% at 1 year, 50% after second episode
— Chronic pleuritic pain
— Bronchopleural fistula with chronic air leak
— Trapped lung — visceral pleural fibrosis preventing re-expansion; requires decortication
— Restrictive lung physiology from pleural scarring/pleurodesis
— Targeted temperature management if anoxic injury
— Neurologic prognostication at ≥72h off sedation
— Family discussions about goals of care
Key distinction: Re-expansion pulmonary edema is unilateral on the decompressed side and develops within hours — distinguish from cardiogenic pulmonary edema (bilateral, with elevated BNP).
Board pearl: Massive output >1500 mL initially or >200 mL/hr ×4 hours through chest tube after trauma → thoracotomy indicated for ongoing hemorrhage.
— Tension pneumothorax (all should be in monitored setting post-decompression)
— Hemodynamic instability or vasopressor requirement
— Hypoxemia requiring high FiO₂ or mechanical ventilation
— Bilateral pneumothorax
— Hemopneumothorax with significant output
— Pneumothorax in mechanically ventilated patient
— Post-arrest patient
— Persistent air leak >5 days
— Massive hemothorax (>1500 mL initial output or >200 mL/hr ×4h)
— Recurrent ipsilateral pneumothorax (2nd episode)
— First contralateral pneumothorax
— Bilateral pneumothorax
— Failed tube management (incomplete lung re-expansion)
— Suspected bronchopleural fistula or tracheobronchial injury
— High-risk profession (pilot, diver) after first episode
— Underlying bullous disease requiring resection
— Secondary spontaneous pneumothorax workup (LAM, BHD, α1-AT, CF)
— Recurrent catamenial pneumothorax (with gynecology co-management)
— HIV-associated pneumothorax with PCP
— Stable simple pneumothorax with chest tube, no leak
— Observation candidates who need serial CXRs
— Very small (<2 cm) primary spontaneous, asymptomatic, reliable patient, close follow-up in 24–48h
— Recent literature (Hallifax 2020) supports conservative outpatient management in select stable cases — but Step 3 default remains admission for new pneumothorax
— Lack of thoracic surgery, ICU capacity, or interventional radiology at the facility for complex cases
— Stabilize first (decompress, chest tube, secure airway) before transport
CCS pearl: A ventilated patient with new pneumothorax should be in the ICU regardless of size — barotrauma risk and rapid evolution to tension justify the upgrade.
Step 3 management: Order ICU admission, continuous cardiac monitoring, hourly vitals, q6h CXR initially, and thoracic surgery consult for any persistent leak or recurrence.
— Same exam findings (decreased breath sounds, hyperresonance) but without hemodynamic compromise
— No tracheal deviation, no JVD
— Manage with observation, O₂, or tube thoracostomy depending on size
— Trauma with dullness to percussion (vs hyperresonance), decreased breath sounds, hypotension
— Initial chest tube output >1500 mL or >200 mL/hr → thoracotomy
— Often coexists with pneumothorax (hemopneumothorax)
— Dullness, decreased breath sounds, gradual onset over days
— POCUS clarifies fluid vs air
— Causes: CHF, malignancy, parapneumonic, hepatic hydrothorax
— Febrile, ill-appearing, loculated pleural fluid
— Requires drainage + antibiotics
— Bowel sounds in chest, NG tube curling into thorax on CXR
— Surgical emergency
— Persistent air leak through chest tube
— Post-pneumonectomy or post-tube
— Tracheal deviation toward the affected side (vs away in tension pneumothorax)
— Decreased breath sounds, dullness
— Trauma with hypoxia and patchy infiltrates on CT
— No pleural air
— Unilateral wheezing, decreased breath sounds, tracheal deviation toward affected side from atelectasis
— Bronchoscopy diagnostic and therapeutic
— Bilateral wheezing, hyperresonance — can mimic but usually symmetric
— Watch for secondary pneumothorax complicating exacerbation
— Recent intubation with unilateral absent breath sounds → pull tube back 2–3 cm and reassess; CXR confirms
Key distinction: Tracheal deviation away = tension pneumothorax (something pushing). Tracheal deviation toward = atelectasis/collapse (something pulling). High-yield exam discriminator.
Board pearl: Right mainstem intubation is the most common cause of acute unilateral absent breath sounds in the ICU — always check ETT depth before calling tension pneumothorax.
— Beck's triad: hypotension, JVD, muffled heart sounds
— Pulsus paradoxus >10 mmHg, electrical alternans on ECG
— POCUS: pericardial effusion with RV diastolic collapse
— Shares JVD and hypotension with tension pneumothorax — POCUS is the differentiator
— Treatment: pericardiocentesis
— Sudden dyspnea, hypoxia, hypotension, tachycardia
— Clear breath sounds bilaterally (vs absent unilaterally in PTX)
— RV strain on echo, S1Q3T3 on ECG, elevated d-dimer/troponin
— CT-PA or empiric thrombolytics if arresting
— Chest pain, hypotension, pulmonary edema (bilateral crackles)
— ECG changes, troponin elevation
— Breath sounds typically present bilaterally
— Tearing chest/back pain, BP differential between arms, widened mediastinum
— May cause pericardial tamponade or hemothorax
— Warm shock, fever, source identifiable
— Usually clear or bilateral lung findings
— Urticaria, angioedema, wheezing, hypotension
— Treat with epinephrine
— Trauma context, FAST positive for free fluid
— Clear lungs
— Post-central line, dialysis, surgery; sudden cardiopulmonary collapse
— Left lateral Trendelenburg, 100% O₂, hyperbaric if available
— Hypotension with bradycardia (vs tachycardia in tension PTX), warm extremities
— Trauma history with neurologic deficit
Key distinction: In undifferentiated shock with respiratory distress, POCUS rapidly differentiates the four killers: tension PTX (absent sliding), tamponade (effusion + RV collapse), massive PE (dilated RV, McConnell sign), and hypovolemia (collapsed IVC, hyperdynamic LV).
Board pearl: RUSH exam (Rapid Ultrasound in Shock) is the Step 3-favored framework for undifferentiated hypotension — pump, tank, pipes.
— Smokers have 20× recurrence risk vs nonsmokers
— Offer behavioral counseling + pharmacotherapy (varenicline first-line, bupropion, nicotine replacement)
— Reassess at every visit; document quit attempts
— Avoid strenuous exertion, contact sports, heavy lifting for 2–4 weeks after resolution (variable by source)
— Avoid Valsalva maneuvers (forced exhalation against resistance, scuba, free diving)
— Wait at least 1–2 weeks after radiographic resolution before commercial flight (BTS recommends 1 week; some say 2)
— Commercial cabins pressurized to ~8000 ft → potential air expansion
— Permanent contraindication to SCUBA diving unless definitive surgical pleurodesis performed
— Indications: 2nd ipsilateral episode, 1st contralateral, bilateral, persistent leak, hemopneumothorax, high-risk profession, large bullae
— VATS bullectomy + mechanical/chemical pleurodesis — gold standard; recurrence <5%
— Chemical pleurodesis via chest tube (talc, doxycycline) — alternative for poor surgical candidates
— COPD: optimize bronchodilators, inhaled steroids per GOLD; pulmonary rehab; vaccinations (influenza, pneumococcal, COVID, RSV)
— Asthma: step-up therapy per GINA
— CF: standard CFTR modulator therapy, airway clearance
— α1-antitrypsin deficiency: augmentation therapy if severe
— LAM: sirolimus
— HIV: ART optimization, PCP prophylaxis if CD4 <200
— Sudden recurrent dyspnea, chest pain, lightheadedness → ED immediately
Step 3 management: At discharge, prescribe varenicline 0.5 mg PO daily ×3 days, then 0.5 mg BID ×4 days, then 1 mg BID ×12 weeks for any smoker; schedule pulmonology follow-up in 2–4 weeks with repeat CXR.
Board pearl: Recurrence rate of primary spontaneous pneumothorax after first episode is ~30%; after second, ~50% — second episode = surgical indication.
— Full lung re-expansion on CXR
— No air leak ×24h on water seal
— No reaccumulation 4–6h after tube removal
— Pain controlled on oral analgesia
— Ambulatory and tolerating diet
— CXR at 2 weeks post-discharge to confirm sustained resolution
— Pulmonology follow-up at 2–4 weeks
— Thoracic surgery follow-up at 4–6 weeks if VATS performed
— Primary care follow-up at 1–2 weeks for medication reconciliation, smoking cessation reinforcement
— Symptoms: recurrent pain, dyspnea, fever (empyema), hemoptysis
— Wound site: signs of infection, hernia, persistent drainage
— Pulmonary function tests at 6–12 weeks if baseline lung disease
— Incentive spirometry 10× per hour while awake during recovery
— Early ambulation reduces atelectasis and DVT
— Gradual return to activity: light activity at 1 week, moderate at 2–4 weeks, full unrestricted at 4–6 weeks (varies)
— Pulmonary rehab referral for COPD/secondary pneumothorax
— Smoking cessation reinforcement at every visit
— Recurrence warning signs and when to return to ED
— Air travel timing and SCUBA permanent restriction
— Importance of identifying family history (BHD syndrome) and screening relatives if hereditary cause found
— Mental health screen — post-ICU PTSD risk in patients who arrested or were ventilated
— Clear discharge summary to PCP with details of tube duration, complications, pending studies
— Medication reconciliation (resume anticoagulants per plan)
— Patient education materials (visual diagrams of recurrence warning signs)
— Confirm follow-up appointments scheduled before discharge
CCS pearl: Always order "schedule follow-up chest X-ray in 2 weeks" and "pulmonology referral" on the CCS discharge plan for any pneumothorax patient.
Step 3 management: Document advice on air travel, diving, smoking cessation, and recurrence symptoms — these are testable transition-of-care items.
— Tension pneumothorax meets implied consent criteria — life-threatening, patient unable to consent, no surrogate available → proceed with needle decompression and chest tube
— Document the emergency nature, attempts to reach family, and clinical justification
— When patient is awake and competent (stable simple pneumothorax), obtain standard written informed consent including risks: bleeding, infection, organ injury, re-expansion edema, recurrence
— For unconscious patients with time, follow state-defined hierarchy (spouse → adult children → parents → siblings)
— Document the surrogate identity and conversation
— Penetrating chest trauma (gunshot, stab wounds) → mandatory law enforcement reporting in most US states
— Suspected child abuse with thoracic trauma → child protective services
— Suspected intimate partner violence → offer resources; reporting requirements vary by state
— Wrong-site thoracostomy is a never-event — use universal protocol: time-out, mark site, verify with imaging and exam
— Bilateral pneumothorax requires careful side identification
— Document side, site, depth of insertion, output, and complications
— Even in emergencies, brief verbal confirmation of patient, side, procedure is feasible and reduces wrong-side errors
— Chest tube removal handoff: clear documentation of removal time, post-removal CXR plan, and signs of recurrence
— Ventilated patient transfers: communicate barotrauma risk; ensure decompression equipment available during transport
— Discharge: confirm patient understands return precautions, especially given recurrence risk
— Post-arrest pneumothorax survivors: timely goals-of-care conversation with family, especially if anoxic brain injury
— Iatrogenic pneumothorax (post-central line, post-biopsy) requires honest disclosure to the patient per AMA ethics; document the discussion
— Pilots and divers require occupational clearance after pneumothorax — providers have a duty to document and communicate restrictions
Board pearl: Iatrogenic pneumothorax after central line placement → disclose to patient, document, place chest tube as needed, and complete an institutional safety event report — failure to disclose violates ethical standards.
Step 3 management: Use ultrasound guidance for all central line placements (subclavian still allows confirmation post-procedure with CXR) to reduce iatrogenic pneumothorax rate — a measurable patient safety indicator.
— Tall, thin males 10–30 yo → primary spontaneous pneumothorax from apical blebs
— Marfan, Ehlers-Danlos, homocystinuria → connective tissue spontaneous PTX
— Reproductive-age women → LAM (with chylothorax, renal angiomyolipomas) or catamenial (thoracic endometriosis)
— Older men with kidney tumors and skin fibrofolliculomas → Birt-Hogg-Dubé syndrome (basilar cysts)
— Young COPD → α1-antitrypsin deficiency
— HIV with CD4 <200 → PCP-associated pneumothorax
— Subclavian > IJ central line for pneumothorax risk
— Transbronchial biopsy → 1–6% pneumothorax rate
— Thoracentesis → 1–5%, lower with ultrasound guidance
— Acupuncture, intercostal nerve block — rare but reported
— Deep sulcus sign on supine CXR — abnormally lucent costophrenic angle
— Lung point on POCUS — 100% specific
— Stratosphere/barcode sign on M-mode — absent sliding
— Continuous diaphragm sign — pneumomediastinum
— High-flow O₂ accelerates resorption ~4× — useful for small stable pneumothoraces
— Nitrous oxide contraindicated (expands closed gas spaces)
— ATLS now favors 5th ICS anterior axillary line for needle decompression in adults
— Chest tube "triangle of safety": lateral border pec major, anterior border lat dorsi, base 5th ICS
— Persistent air leak >5 days → VATS
— Re-expansion edema after rapid drainage of chronic large PTX
— Pneumothorax size formula (Light): % = 100 − (lung volume/hemithorax volume × 100)
— Massive hemothorax: initial output >1500 mL or >200 mL/hr ×4h → thoracotomy
— 30% after 1st PSP, 50% after 2nd, 80% after 3rd
— Bleomycin, paclitaxel, bevacizumab → reported pulmonary toxicity with PTX
— Cocaine, marijuana → barotrauma from Valsalva inhalation
Board pearl: Cyclical right-sided chest pain in a 30-year-old woman timed to menses → catamenial pneumothorax from thoracic endometriosis; VATS + hormonal suppression.
"A 24-year-old man arrives after MVC. BP 80/40, HR 130, RR 32, SpO₂ 84%. Trachea deviated to the right, absent breath sounds on left, hyperresonance to percussion left. What is the next best step?"
→ Immediate needle decompression or finger thoracostomy at left 5th ICS anterior axillary line. Wrong answers: CXR, CT chest, IV fluids first, intubation.
"A 60-year-old intubated for ARDS suddenly develops BP 70/40, peak airway pressures rise from 30 to 55, SpO₂ drops to 80%, breath sounds absent on right."
→ Decompress immediately; barotrauma is the answer.
"30 minutes after subclavian central line placement, the patient develops dyspnea and chest pain. BP 110/70, breath sounds decreased on right."
→ Stable pneumothorax — order upright CXR, then tube thoracostomy if symptomatic/large. If hypotensive added, decompress first.
"A 22-year-old, 6'3", 150 lb, smoker, sudden left chest pain at rest. Stable vitals. Decreased breath sounds left apex."
→ Primary spontaneous pneumothorax; CXR, manage by size and symptoms.
"A 32-year-old woman with three episodes of right pneumothorax, each within 48 hours of menses."
→ Thoracic endometriosis; VATS + GnRH agonist or OCPs.
"Second ipsilateral spontaneous pneumothorax in a 25-year-old. What's next after resolution?"
→ VATS bullectomy with pleurodesis.
"Obese trauma patient, needle decompression performed, no improvement."
→ Needle too short — proceed to finger thoracostomy or chest tube.
"After draining a large chronic pneumothorax rapidly, patient develops unilateral pulmonary edema."
→ Re-expansion pulmonary edema; supportive care, slow drainage next time.
"Pneumothorax resolved 3 days ago, patient asks about flying."
→ Wait at least 1–2 weeks after radiographic resolution.
"Decreased breath sounds, trachea deviated toward the affected side."
→ Atelectasis or mainstem intubation, NOT tension pneumothorax.
Board pearl: When the stem gives you hemodynamic instability + unilateral exam findings, the answer is always to decompress first, image second.
Tension pneumothorax is a clinical diagnosis — hemodynamic instability plus unilateral absent breath sounds and hyperresonance mandates immediate needle or finger thoracostomy before any imaging, followed by definitive tube thoracostomy.
Board pearl: The single most-tested concept across Step 2 and Step 3 for this topic is "do not delay decompression for a chest X-ray when the patient is unstable" — the clinical exam alone is sufficient to act, and any answer choice that delays therapy for imaging in an unstable patient is wrong.
CCS pearl: Order sequence on CCS — (1) "needle thoracostomy, [side]" or "tube thoracostomy, [side]" → (2) advance clock 15 min → (3) reassess vitals → (4) order portable CXR → (5) ICU admission with continuous telemetry and pulse oximetry → (6) thoracic surgery consult if persistent air leak, hemothorax, or recurrence.