Case studies · Medicine · 31 October 2026

Spontaneous pneumothorax case study

The case

Patient: A 24‑year‑old male, tall (190 cm), thin (BMI 19 kg/m²), non‑smoker.

Presenting complaint: Sudden onset sharp left‑sided chest pain and shortness of breath for 2 hours.

History of presenting illness:

• Pain began while the patient was at rest, described as “knife‑like” and worsened on deep inspiration.
• No trauma, recent cough, fever, or recent travel.
• No previous similar episodes.
• No known chronic lung disease.

Past medical history: Unremarkable. No surgeries.

Family history: Father had asthma; no known hereditary lung disorders.

Social history: University student, occasional alcohol, denies drug use.

Review of systems:

• No fever, chills, or night sweats.
• No wheeze, cough, or sputum.
• No leg swelling or calf pain.

Examination:

Initial investigations:

Questions

1. What is the most likely diagnosis?
2. Which clinical and radiological findings support this diagnosis and why?
3. Outline the classification of spontaneous pneumothorax and indicate which category this patient belongs to.
4. What are the immediate management steps according to the latest (2023) British Thoracic Society (BTS) guidelines?
5. List possible complications and long‑term follow‑up recommendations for this patient.

Answers

1. What is the most likely diagnosis?

Primary Spontaneous Pneumothorax (PSP) – a pneumothorax occurring in a patient without underlying lung disease, typically young, tall, thin males.

Rationale:

• Sudden, unilateral pleuritic chest pain and dyspnoea.
• Absence of trauma or iatrogenic cause.
• No history of chronic lung disease or smoking.
• Physical signs (hyperresonance, decreased breath sounds) and imaging confirming air in the pleural space.

2. Which clinical and radiological findings support this diagnosis and why?

3. Outline the classification of spontaneous pneumothorax and indicate which category this patient belongs to.

Classification (BTS 2023):

Patient’s category: Primary Spontaneous Pneumothorax (PSP) – because he has no known lung disease, is a young tall male, and the precipitating factor is likely rupture of a subpleural bleb. The mild mediastinal shift does not meet the hemodynamic criteria for tension pneumothorax.

4. What are the immediate management steps according to the latest (2023) British Thoracic Society (BTS) guidelines?

Step‑wise approach:

1. Assess clinical stability

   • Stable: HR < 120, SBP > 90 mm Hg, SpO₂ ≥ 90 % on room air, no severe dyspnoea.
   • Unstable (tension): hypotension, severe tachycardia, tracheal deviation → immediate needle decompression.

   Our patient is borderline stable (HR 112, SpO₂ 92 %).

2. Size estimation on chest X‑ray

   • Small: <2 cm between lung margin and chest wall at the level of the hilum.
   • Large: ≥2 cm.

   Measured distance ≈3 cm → large PSP.

3. Initial treatment for a large, stable PSP

   • Needle aspiration (first‑line)

     • 14‑16 G cannula, inserted in the 2nd intercostal space, mid‑clavicular line (or 5th intercostal space, anterior axillary line).
     • Attach to a 3‑way stopcock, allow air to escape, then remove.
     • Success rate ≈ 70 % (BTS 2023).

   • If aspiration fails (no radiological improvement or persistent symptoms) → Chest tube (intercostal drain, ICD) insertion

     • 12‑14 F small‑bore tube, placed in the 5th intercostal space, mid‑axillary line.
     • Connect to an underwater seal or digital drainage system.

4. Oxygen therapy

   • Administer high‑flow supplemental O₂ (≥4 L/min via nasal cannula or face mask) to hasten pleural air resorption (≈30 % faster per 1 L increase in FiO₂).

5. Observation

   • Repeat chest X‑ray 4 hours after aspiration or 6‑12 hours after chest tube insertion to confirm lung re‑expansion.

6. Analgesia & anti‑emetics

   • Paracetamol 1 g IV/PO q6h; consider low‑dose morphine if severe pain.

7. Discharge criteria (if aspiration successful)

   • Stable vitals for ≥2 hours, SpO₂ ≥ 94 % on room air, chest X‑ray shows >90 % lung re‑expansion, and patient can ambulate.

Algorithm summary for this patient:

• Large PSP, clinically stable → attempt needle aspiration.
• If aspiration unsuccessful or recurrence within 24 h → place ICD.

5. List possible complications and long‑term follow‑up recommendations for this patient.

Complications:

1. Recurrence – up to 30 % within 1 year; higher after first episode.
2. Tension pneumothorax – if air continues to enter pleural space without exit.
3. Hemothorax – rare, usually iatrogenic from chest tube insertion.
4. Infection of pleural space (empyema) – especially with prolonged chest tube drainage.
5. Persistent air leak (>5 days) – may require surgical intervention (VATS).

Long‑term follow‑up:

Key learning points

• PSP typically occurs in tall, thin young males due to rupture of subpleural blebs.
• Classic bedside signs: unilateral hyperresonance, decreased tactile fremitus, and diminished breath sounds.
• Chest X‑ray showing a visceral pleural line with absent peripheral lung markings confirms pneumothorax; ultrasound “lung point” is 100 % specific.
• BTS 2023 recommends needle aspiration as first‑line for large, stable PSP; chest tube is reserved for failed aspiration or unstable patients.
• High‑flow oxygen accelerates pleural air resorption (≈30 % faster per 1 L increase in FiO₂).
• Recurrence is common; consider CT scanning and surgical pleurodesis after the second episode.
• Immediate recognition of tension physiology (hypotension, tracheal deviation) mandates emergent needle decompression.
• Follow‑up imaging and patient education are essential to prevent morbidity from recurrence.

Practice MCQs

1. A 27‑year‑old tall male presents with sudden left‑sided chest pain and dyspnoea. Chest X‑ray shows a 3 cm rim of air without mediastinal shift. He is haemodynamically stable. According to BTS 2023, the next best step is:

A. Immediate insertion of a large‑bore chest tube (24 F)
B. Observation only, no intervention needed
C. Needle aspiration with a 14‑G cannula
D. High‑dose intravenous steroids

Answer: C — Needle aspiration is the first‑line treatment for a large, stable primary spontaneous pneumothorax.

2. Which of the following findings on thoracic ultrasound is pathognomonic for pneumothorax?

A. B‑lines
B. Lung sliding
C. Lung point
D. Pleural effusion

Answer: C — The “lung point” (transition between sliding and absent sliding) is 100 % specific for pneumothorax.

3. After successful needle aspiration of a primary spontaneous pneumothorax, the patient should be advised to avoid which activity for at least 2 weeks?

A. Walking on level ground
B. Driving a car
C. Scuba diving
D. Reading a book

Answer: C — Positive‑pressure changes during scuba diving can precipitate recurrence; avoidance for 2 weeks (or until radiological resolution) is recommended.

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