Emergency Medicine

BREATHLESS PATIENT

General Medical Emergencies 73

5 A spontaneous primary pneumothorax may cause only slight dyspnoea and
pleuritic chest pain in a fit patient, even when the whole lung is collapsed.
(i) ‘Significant’ dyspnoea is considered any deterioration in usual
exercise tolerance.
(ii) Significant dyspnoea or breathlessness is more common in a
secondary pneumothorax with underlying chronic lung disease,
even if small.

6 Look for reduced chest expansion on the affected side, increased resonance
on percussion, and diminished breath sounds. Beware that lateralizing signs
may be subtle and difficult to confirm.

7 Request a standard inspiratory CXR in all cases.
(i) Do not wait for this if there are signs of tension, but proceed
immediately to insert a wide-bore cannula or intercostal drain
(see p. 471).
(ii) Assess the size of the pneumothorax on the CXR:
(a) small is a visible rim of <2 cm
(b) large is a visible air rim ≥2 cm around all the lung edge, that
represents over 50% of lung volume lost
(c) expiratory CXRs are no longer routine.

MANAGEMENT

This is determined by the presence or absence of chronic lung disease (i.e. a
secondary or a primary pneumothorax), the degree of dyspnoea (significant or
not), and by the size of the pneumothorax (large or small).

1 Discharge a patient with a small ‘primary’ pneumothorax <2 cm, with no
CLD and no significant dyspnoea. No active interventional management is
indicated.
(i) Arrange follow-up by the GP for repeat CXR within 7–14 days,
and refer to a respiratory physician.
(ii) Advise the patient to stop smoking, and to return immediately if
they develop significant dyspnoea.
(iii) Advise them not to fly for at least 1 week after the CXR has
returned to normal, and never to go SCUBA diving (unless they
have had bilateral surgical pleurectomies).

2 Also take no active intervention in a patient with underlying lung disease,
i.e. a ‘secondary’ pneumothorax, who has a small pneumothorax <2 cm with
no significant dyspnoea.
(i) However, admit for observation for 24 h, and start high-flow
oxygen via a face mask, unless they have COPD in which case use
28%.
(ii) Repeat the CXR after 6–12 h and discharge after 24 h only if they
remain asymptomatic and the pneumothorax is not progressing.
Arrange early respiratory or medical follow-up within 7 days.