Pneumothorax

What a Pneumothorax Is

Primary vs. Secondary Spontaneous Pneumothorax

Spontaneous pneumothorax, meaning one that occurs without trauma or a procedure, is divided into two distinct categories based on whether an underlying lung disease is present, and this distinction meaningfully affects how each is evaluated and managed.

Primary vs. Secondary Spontaneous Pneumothorax

Primary vs. Secondary Spontaneous Pneumothorax

Dimension	Primary Spontaneous Pneumothorax	Secondary Spontaneous Pneumothorax
Underlying Lung Disease	None identified	Present, most often COPD, but also interstitial lung disease, cystic fibrosis, or certain infections
Typical Patient	Tall, thin young adults, often smokers	Older adults with known chronic lung disease
Likely Cause	Rupture of small air-filled blebs near the top of the lung	Weakened or diseased lung tissue rupturing, related to the underlying condition
Symptom Severity	Often better tolerated, since the surrounding lung tissue is otherwise healthy	Often more severe, since the surrounding lung already has reduced reserve
General Management Approach	More often eligible for observation or aspiration when small	More often requires drainage, given reduced tolerance for even a modest pneumothorax

Traumatic and Iatrogenic Pneumothorax

Not every pneumothorax is spontaneous. Traumatic pneumothorax results from blunt or penetrating chest injury, including a rib fracture that punctures the lung’s surface. Iatrogenic pneumothorax is a complication of a medical procedure, most often a needle biopsy of the lung, placement of a central venous line, or, as noted on the bronchoscopy page, an uncommon but recognized risk when a lung tissue biopsy is taken during that procedure. New shortness of breath or chest pain after any of these situations should prompt immediate evaluation rather than being dismissed as expected discomfort.

Tension Pneumothorax: A Medical Emergency

This section describes a true medical emergency. A tension pneumothorax develops when air continues to enter the pleural space with each breath but has no way to escape, so pressure builds progressively. That rising pressure pushes the heart and major blood vessels out of their normal position and impairs the heart’s ability to pump blood effectively, which can rapidly become fatal without treatment.

Severe or rapidly worsening shortness of breath, a fast heart rate combined with low blood pressure, bluish discoloration of the lips or skin, and visibly distended neck veins are warning signs. Anyone experiencing these symptoms, particularly after a known pneumothorax, significant chest trauma, or a chest procedure, should call 911 or go to an emergency room immediately rather than waiting to see if symptoms improve on their own.

How Pneumothorax Is Diagnosed

The Diagnostic Pathway

1. 01→Clinical SuspicionSudden chest pain, shortness of breath, recent chest trauma or a chest procedure, or known lung disease raises concern for pneumothorax.↓
2. 02→Chest X-RayThe initial and often sufficient test to confirm a pneumothorax and estimate its size, which guides the initial management decision.↓
3. 03CT Scan, When NeededUsed for a smaller or more complex pneumothorax, or to look for an underlying lung abnormality that may explain a secondary spontaneous pneumothorax.↓
4. 04→Bedside Ultrasound, In Select SettingsCan identify a pneumothorax quickly in an emergency or critical care setting, sometimes before a formal chest X-ray is obtained.↓
5. 05Assessing SeveritySize, symptoms, and whether there are signs of tension pneumothorax together determine urgency and the appropriate next step.

Chest CT imaging is especially useful for identifying underlying lung disease, such as interstitial lung disease or emphysema, that may explain a secondary spontaneous pneumothorax and that would not otherwise be clearly visible on a standard chest X-ray.

Treatment and Management

Management depends primarily on the pneumothorax’s size, a person’s symptoms, and whether an underlying lung disease is present, ranging from simple observation to a procedure.

Observation. A small, minimally symptomatic pneumothorax, particularly a primary spontaneous one, is often managed with monitoring and a follow-up chest X-ray, since the trapped air is gradually reabsorbed by the body on its own. Supplemental oxygen can speed this reabsorption when observation is chosen in a monitored setting.

Needle aspiration. For a moderate-sized, symptomatic pneumothorax without signs of an ongoing large air leak, a needle or small catheter can manually remove trapped air, sometimes avoiding the need for a chest tube.

Chest tube drainage. A large pneumothorax, significant symptoms, tension pneumothorax, or a pneumothorax that does not adequately resolve with needle aspiration generally requires a chest tube, which provides continuous drainage of air over several days while the lung re-expands.

Preventing recurrence. For people with a recurrent pneumothorax, a persistent air leak, or specific risk factors such as bilateral involvement or an occupation like flying or diving, pleurodesis or minimally invasive surgery (VATS) can meaningfully reduce the chance of it happening again by addressing the ruptured tissue directly or creating adhesion that prevents air from reaccumulating.

Preventing Recurrence and Living With a Pneumothorax

Because roughly one in three people who have a first spontaneous pneumothorax go on to have another, and the risk rises further after a second episode, physicians generally discuss recurrence prevention more seriously after a repeat event or when specific risk factors are present. Smoking cessation is strongly advised for anyone with a history of primary spontaneous pneumothorax, since ongoing smoking is one of the strongest modifiable risk factors for it happening again.

Activities that involve significant changes in ambient pressure, most notably air travel and scuba diving, require individualized guidance from a physician after a pneumothorax, since both can be affected by a healing or recurring pneumothorax in ways that are worth discussing before resuming them.

Getting Care Quickly

Sudden chest pain and shortness of breath should never be assumed to be minor without evaluation, and any symptoms suggesting a tension pneumothorax, severe or rapidly worsening breathlessness, a fast heart rate with low blood pressure, or bluish skin, call for emergency care rather than a scheduled appointment.

For patients in the North Dallas-Fort Worth area, the pulmonary team at VitalAir Sleep & Lung Center in Frisco, Texas provides follow-up evaluation and management for pneumothorax, including recurrence-risk discussions, once emergency treatment, if needed, has already taken place.