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A pneumothorax is a collapsed lung. Air escapes into the space between the lung and the chest wall, and the pressure stops the lung from inflating properly, causing sudden chest pain and breathlessness. It can happen out of the blue (often in tall, young, slim people or smokers), from lung disease, or after an injury or medical procedure. Small ones may heal on their own; larger ones need the air drained. This page explains pneumothorax and the important physiotherapy precautions.
Definition
A pneumothorax occurs when air enters the pleural space — the space between the lung and the chest wall — and the lung partially or completely collapses. A tension pneumothorax, where trapped air accumulates under pressure and compresses the heart and great vessels, is an immediately life-threatening emergency requiring decompression before imaging.
Pathophysiology
How the lung collapses
The lung is held expanded by a negative pressure in the pleural space, working against the lung's own elastic recoil and the outward spring of the chest wall. When air breaches either pleural surface — from a ruptured subpleural bleb, diseased lung, injury or a procedure — that negative pressure is lost, the two opposing forces are released, and the lung recoils inwards while the chest wall springs outwards. Gas exchange is impaired both by loss of ventilated lung and by continued blood flow past collapsed tissue, producing shunt and hypoxaemia.
Tension pneumothorax
Where the breach acts as a one-way valve, air enters on inspiration but cannot escape. Pleural pressure becomes positive and rises with every breath, collapsing the lung completely, pushing the mediastinum across, and — the lethal step — kinking the great veins so that venous return and cardiac output fall. The patient becomes hypotensive and hypoxic and will arrest without immediate decompression. Positive-pressure ventilation accelerates this, which is why an undrained pneumothorax is an absolute contraindication to it.
Co-morbidities
Secondary pneumothorax arises against a background of lung disease — COPD and emphysema, asthma, cystic fibrosis, interstitial lung disease, previous tuberculosis, lung cancer and necrotising infection. These conditions make an episode considerably more dangerous, because there is little reserve to lose, and more likely to recur. Smoking is the dominant modifiable risk factor. Connective tissue disorders such as Marfan and Ehlers–Danlos syndromes, and catamenial pneumothorax related to thoracic endometriosis, account for a small but recognisable group of younger patients.
Prevalence
Primary spontaneous pneumothorax occurs at roughly 18–28 per 100,000 men and 1–6 per 100,000 women per year, typically in tall, slim young adults, and overwhelmingly in smokers. Secondary spontaneous pneumothorax occurs in older people with established lung disease and carries far higher morbidity. Recurrence after a first primary spontaneous episode is common — of the order of a quarter to a third within a year, higher again in continuing smokers — and this recurrence risk drives most management decisions.
Causes and risk factors
- Primary spontaneous — without clinically apparent lung disease, from rupture of small subpleural blebs.
- Secondary spontaneous — complicating COPD, asthma, cystic fibrosis, interstitial lung disease, infection or malignancy.
- Traumatic — penetrating or blunt chest injury, including rib fractures.
- Iatrogenic — central line insertion, transbronchial or CT-guided lung biopsy, pleural aspiration, and positive-pressure ventilation.
- Smoking — increases the risk of a first spontaneous pneumothorax roughly nine-fold in women and twenty-fold in men, in a clear dose-dependent relationship, and remains the single most modifiable factor for recurrence.1
- Tall, slim body habitus in young adults, and a family history in a minority.
Symptoms
Typical features
- Sudden, sharp, one-sided pleuritic chest pain, often at rest rather than during exertion.
- Breathlessness, which may be mild in a young person with a small pneumothorax and severe in someone with underlying lung disease.
- Reduced chest expansion, absent breath sounds and a hyper-resonant percussion note on the affected side.
- In secondary pneumothorax, symptoms are markedly disproportionate to the size of the air collection.
Tension pneumothorax
Recognising recurrence
A recurrent pneumothorax usually feels like the first: abrupt one-sided pain with breathlessness. Patients who have had one should be told plainly what to look for and instructed to present rather than wait, since a second event on an already compromised lung is less well tolerated.
Diagnosis
Why diagnosis matters
Diagnosis separates a small, stable pneumothorax that can safely be observed from a tension pneumothorax needing immediate decompression, and identifies underlying lung disease that changes both the acute management and the recurrence risk. It also matters in the other direction: recognising that an undrained pneumothorax contraindicates several routine respiratory interventions.2
How is it diagnosed?
An erect chest X-ray is the standard initial test, showing a visible visceral pleural line with absent lung markings beyond it. Thoracic ultrasound is more sensitive in the supine, trauma or critical care setting, where absent lung sliding is the key finding. CT is the reference standard, sizes the pneumothorax accurately and reveals blebs, emphysema or interstitial disease.
Sizing and classification
Size guides management but does not override the clinical picture. Contemporary guidance places more weight on symptoms and physiological stability than on a millimetre threshold: a symptomatic patient with a small pneumothorax and poor reserve needs intervention, while an asymptomatic patient with a moderate one may not.
Distinguishing pneumothorax from bullous disease
A large emphysematous bulla can closely mimic a pneumothorax on plain film, and draining one is a serious error producing a persistent air leak. Where there is any doubt in a patient with emphysema, CT is obtained before intervention.
Investigations for related conditions
After the acute episode, CT looks for blebs, emphysema or interstitial disease that would raise recurrence risk and inform surgical decisions. Smoking status is addressed as a treatment, not a lifestyle note. In young women with recurrent right-sided events, catamenial pneumothorax is considered, and connective tissue disease is screened for where habitus or family history suggests it.
Management
Management and goals
The goals are to relieve symptoms, re-expand the lung, prevent tension, and reduce recurrence — balanced against avoiding unnecessary intervention, since many pneumothoraces resolve without it. Management has shifted markedly towards conservative and ambulatory care over the past decade.
Conservative management
Observation is appropriate for small, minimally symptomatic primary spontaneous pneumothorax. A randomised trial of conservative versus interventional management found conservative treatment non-inferior for lung re-expansion at eight weeks, with fewer adverse events and a lower rate of recurrence — establishing observation as a legitimate first choice in selected patients rather than a compromise.3
Aspiration and ambulatory management
Needle aspiration is a reasonable first intervention for larger primary spontaneous pneumothorax. Ambulatory devices with a one-way valve allow the patient to go home with the device in situ: this significantly shortened hospital stay compared with standard care, at the cost of more adverse events, making patient selection and clear follow-up essential.4
Chest drain
An intercostal drain is used for large, symptomatic, secondary or traumatic pneumothorax, and where aspiration has failed. Suction is not applied routinely and is added only for persistent air leak or failure to re-expand, in discussion with the respiratory or surgical team.
Surgery
Video-assisted thoracoscopic surgery with bullectomy and pleurodesis or pleurectomy is indicated for recurrence, persistent air leak beyond three to five days, bilateral events, first episodes in high-risk occupations such as diving and aviation, and secondary pneumothorax with poor reserve. Surgical intervention reduces recurrence to low single-figure percentages, against a substantial baseline recurrence risk after conservative management alone.5
Identifying deterioration
Increasing breathlessness, rising oxygen requirement, hypotension, a drain that stops bubbling in a patient who has not improved, or surgical emphysema spreading rapidly all warrant urgent review. Any patient with a pneumothorax who deteriorates suddenly should be assessed for tension.
Medications
Analgesia and oxygen
There is no specific drug treatment; management is procedural. Adequate analgesia matters because pleuritic pain causes splinting and shallow breathing. High-flow oxygen accelerates pleural air resorption in conservatively managed inpatients by increasing the nitrogen gradient, and is used with the usual caution in those at risk of carbon dioxide retention.
Smoking cessation as prevention
The most important preventive prescription is smoking cessation, which substantially reduces recurrence. It is offered as active treatment with pharmacotherapy and behavioural support at the index admission, when motivation is highest, rather than mentioned in passing at discharge.
Living with pneumothorax
Recovery and activity
Most people return to normal activity within a few weeks. Strenuous exertion and contact sport are usually deferred until re-expansion is confirmed and symptoms have settled. There is no need to avoid ordinary exercise long-term after full resolution.
Flying
Air travel is deferred until the pneumothorax has fully resolved on imaging, with a further interval — the British Thoracic Society advises not travelling until seven days after full resolution on chest X-ray — because cabin depressurisation expands any residual air. After thoracic surgery the interval is longer: commonly four weeks for non-essential travel and a minimum of two weeks where travel is essential, on the surgeon's advice. Anyone who has had a pneumothorax within the last six weeks, and anyone at higher risk of recurrence — including cystic lung disease such as lymphangioleiomyomatosis or Birt-Hogg-Dubé syndrome — warrants specialist assessment before flying. After open surgical pleurodesis the recurrence rate is low enough that no travel restriction applies, though recurrence is appreciably more common after the thoracoscopic equivalent.66 Advice is individualised and documented, particularly for patients who fly for work.
Diving
Diving is generally contraindicated permanently after a spontaneous pneumothorax unless definitive surgical treatment has been performed, because ascent expands trapped gas and can cause tension. This has occupational consequences for commercial and military divers and should be discussed early and explicitly.
Smoking cessation
Continued smoking is the strongest modifiable predictor of recurrence, and the risk falls substantially after stopping. This is worth revisiting at every contact rather than once.
Recognising recurrence and planning ahead
Patients should know the symptoms of recurrence, that they should present rather than wait, and — for those with underlying lung disease — that they should mention their history at any hospital attendance, since it changes decisions about ventilation and pleural procedures.
Prognosis
Most pneumothoraces resolve well with appropriate management, and primary spontaneous pneumothorax in an otherwise healthy young person carries an excellent outlook. The principal issue is recurrence, which surgery largely prevents. Secondary pneumothorax in significant lung disease is a different proposition: mortality is appreciable, resolution is slower, persistent air leak is more common, and the threshold for definitive intervention is correspondingly lower. Long-term lung function is usually unaffected after a treated primary pneumothorax.
Role of the physiotherapist
Contraindications and cautions
Physiotherapy here begins with knowing what not to do. An undrained pneumothorax is a contraindication to positive-pressure techniques — intermittent positive pressure breathing, non-invasive ventilation and CPAP — and to positive expiratory pressure and oscillating PEP devices, because raising airway pressure can enlarge it or convert it to tension. Vigorous manual techniques over the affected area are also avoided. These are established safety considerations in cardiorespiratory practice,7 and pneumothorax is explicitly recognised as a relative contraindication in non-invasive ventilation guidance.8 A drained pneumothorax with a functioning drain changes the calculation, but only in discussion with the treating team. Where a patient with a chronic sputum-producing condition develops a pneumothorax, the clearance regimen is modified rather than continued unchanged — gravity-assisted positioning and manual assistance in place of PEP, until it is safe to resume.
Rehabilitation after resolution
Once resolved or safely drained, physiotherapy supports lung re-expansion with gentle thoracic expansion breathing, posture correction and shoulder mobility on the affected side, which is readily lost to guarding after a drain or thoracotomy. Early mobilisation and graded return to activity follow, with structured recovery pathways after surgical management,9 and progression guided by symptoms and imaging rather than a fixed timetable. Education is a substantial part of the role: what happened, why it may recur, what to do if it does, and why smoking cessation is the treatment rather than the advice.
Part 1 · References
- Bense L, Eklund G, Wiman LG. Smoking and the increased risk of contracting spontaneous pneumothorax. Chest 1987;92(6):1009–1012.
- Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society guideline for pleural disease. Thorax 2023;78(Suppl 3):s1–s42.
- Brown SGA, Ball EL, Perrin K, et al. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med 2020;382(5):405–415.
- Hallifax RJ, McKeown E, Sivakumar P, et al. Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial. Lancet 2020;396(10243):39–49.
- Walker SP, Bibby AC, Halford P, Stadon L, White P, Maskell NA. Recurrence rates in primary spontaneous pneumothorax: a systematic review and meta-analysis. Eur Respir J 2018;52(3):1800864.
- Coker RK, Armstrong A, Church AC, et al. BTS Clinical Statement on air travel for passengers with respiratory disease. Thorax 2022;77(4):329–350. Updates the 2011 BTS recommendations.
- Reeve J, Ntoumenopoulos G, Denehy L, et al. Cardiorespiratory physiotherapy in the adult intensive care unit: safety considerations and contraindications to treatment. Physiother Theory Pract 2021;37(1):1–12.
- Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017;50(2):1602426.
- Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the ERAS Society and the European Society of Thoracic Surgeons. Eur J Cardiothorac Surg 2019;55(1):91–115.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
More than one of our services applies here, and which combination suits you depends on what your assessment shows.
Clinical evidence
Part 1 covers the same condition without the technical detail. What follows is the evidence base behind it, written for clinicians — the literature, the reasoning and the gaps.
For clinicians: this summary supports clinical reasoning and is not a protocol. Check current guidelines and local policy before applying it, and read it alongside the key references and guidelines directory.
Framing. Management of primary spontaneous pneumothorax has shifted decisively toward doing less. The Australasian randomised trial by Brown and colleagues found conservative observation non-inferior to interventional drainage for lung re-expansion at eight weeks, with fewer adverse events and fewer recurrences, and the 2023 BTS guideline now frames the decision around symptoms, risk and patient priorities rather than the size of the rim on a chest radiograph.1,2 Ambulatory devices offer a third path, reducing hospital stay at the cost of more adverse events.3
Treatment evidence
- Conservative management is non-inferior in selected, clinically stable patients with moderate-to-large primary spontaneous pneumothorax, and avoids the procedural harms of drainage.1
- Ambulatory management with a one-way-valve device shortened hospital stay compared with standard care in RAMPP, but with a higher rate of adverse events, so it is a selected-patient strategy.3
- Needle aspiration is less invasive than intercostal drainage with comparable success in primary pneumothorax, and remains an option where intervention is chosen.2
- Secondary spontaneous pneumothorax is a different disease: in COPD, cystic fibrosis or fibrotic lung disease, reserve is limited, deterioration is faster, and intervention plus admission is generally required.2
- Recurrence after a first primary event is substantial (of the order of a quarter to a third), driving surgical pleurodesis or bullectomy after a second event, or after a first event in high-risk occupations.2,4
- Smoking multiplies risk markedly and cessation reduces recurrence — the single most useful piece of advice at discharge.5
Physiotherapy safety evidence
- An undrained pneumothorax is a contraindication to positive-pressure therapy — NIV, CPAP, IPPB, mechanical insufflation–exsufflation, high-pressure PEP and manual hyperinflation risk converting a simple pneumothorax to a tension pneumothorax.6,7
- Positive-pressure therapy is a recognised cause of pneumothorax and barotrauma, which is why the caution is categorical rather than relative.7
- Early mobilisation with a chest drain in situ is safe and is recommended in thoracic enhanced-recovery guidance.8
- Air travel and diving: BTS advises not flying until seven days after full resolution on chest X-ray, with a longer interval after thoracic surgery (commonly four weeks, or a minimum of two if travel is essential) and specialist assessment for anyone with a pneumothorax in the preceding six weeks or at higher risk of recurrence. Diving is permanently contraindicated unless definitive surgical pleurectomy has been performed.2,9
Physiotherapy implications
- Check for a current or recent pneumothorax before any positive-pressure intervention. This is the single most important safety screen in acute respiratory physiotherapy, and it includes patients on NIV pathways and cough-assist devices.6,7
- Do not percuss or vibrate over the affected hemithorax, and avoid forceful huffing and breath-hold manoeuvres in the acute phase.
- Mobilise where the drain and the patient allow — upright and walking, drainage system below insertion level, never clamping a bubbling drain, in coordination with nursing.8
- In a patient with cystic fibrosis or bronchiectasis and a pneumothorax, clearance must continue in some form but be re-planned with the treating team — low-pressure, gravity-assisted and gentle techniques, and no PEP or oscillating devices until sanctioned.2
- Rebuild afterwards: thoracic mobility, shoulder range on the drain side, posture, graded return to exercise and, in throwing or contact athletes, a staged return discussed with the treating team.
- Escalate immediately for sudden increasing breathlessness, chest pain, tracheal deviation, distended neck veins, hypotension or rapidly expanding surgical emphysema — tension pneumothorax is a treat-now emergency.
- Deliver smoking-cessation advice at every contact and explain the recurrence link explicitly; it is more persuasive here than in almost any other condition.5
Clinical reasoning
- Sudden unilateral pleuritic chest pain with breathlessness in a tall young smoker, or in anyone with emphysema or fibrosis, is pneumothorax until imaging says otherwise — withhold treatment and refer.
- Reduced expansion, hyper-resonance and absent breath sounds on one side is a mechanical problem; no clearance technique addresses it.
- Sudden deterioration in a ventilated or NIV-supported patient should raise pneumothorax before anything else.7
- Conservative management is not the same as no follow-up: these patients need clear escalation instructions and review, and physiotherapy is a good place to check they have them.1
Evidence gaps
- No trial has tested any physiotherapy intervention in pneumothorax; the safety rules rest on mechanism and case reports rather than randomised data.6,7
- Optimal timing of return to exercise, sport and heavy work after resolution is not evidence-based.
- Selection criteria for conservative versus ambulatory versus interventional management are still being refined outside trial populations.1,3
- How to safely maintain airway clearance in cystic fibrosis or bronchiectasis complicated by pneumothorax has never been studied.
References for the clinical evidence summary
- Brown SGA, Ball EL, Perrin K, et al. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med 2020;382(5):405–415.
- Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society guideline for pleural disease. Thorax 2023;78(Suppl 3):s1–s42.
- Hallifax RJ, McKeown E, Sivakumar P, et al. Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial. Lancet 2020;396(10243):39–49.
- Walker SP, Bibby AC, Halford P, Stadon L, White P, Maskell NA. Recurrence rates in primary spontaneous pneumothorax: a systematic review and meta-analysis. Eur Respir J 2018;52(3):1800864.
- Bense L, Eklund G, Wiman LG. Smoking and the increased risk of contracting spontaneous pneumothorax. Chest 1987;92(6):1009–1012.
- Reeve J, Ntoumenopoulos G, Denehy L, et al. Cardiorespiratory physiotherapy in the adult intensive care unit: safety considerations and contraindications to treatment. Physiother Theory Pract 2021;37(1):1–12.
- Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017;50(2):1602426.
- Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the ERAS Society and the European Society of Thoracic Surgeons. Eur J Cardiothorac Surg 2019;55(1):91–115.
- Coker RK, Armstrong A, Church AC, et al. BTS Clinical Statement on air travel for passengers with respiratory disease. Thorax 2022;77(4):329–350. Updates the 2011 BTS recommendations.
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