In this episode of Hospital Medicine Unplugged, we tackle pneumothorax in the inpatient world—stabilize first, size it right, choose the least invasive path that’s safe, and never miss tension physiology.

We open with the first five minutes: is the patient stable? Check vitals and work of breathing, then confirm with imaging—CXR first-line, POCUS for speed/supine patients, CT when the picture’s hazy or occult. If tension is suspected, treat now—don’t wait for imaging. Tube thoracostomy is definitive.

Classification that actually changes management: primary spontaneous (PSP), secondary spontaneous (SSP), iatrogenic, traumatic, and tension. But modern imaging blurs PSP vs SSP—let size + symptoms drive decisions, with special caution in SSP and ventilated patients.

Conservative lane (when it’s safe):
• Stable PSP, minimal symptoms → observation ± oxygen. Recent trials show noninferior 8-week re-expansion, fewer procedures, shorter LOS. Selection matters: reliable follow-up, no significant compromise.
• Iatrogenic, small, asymptomatic → observe and re-image.

Interventional lane (when to act):
• Significant symptoms, large size, instability, or failed observation.
• Needle aspiration can succeed in ~70% of stable PSP and may avoid admission; recurrence similar to tubes but shorter stays.
• If aspiration fails/contraindicated or SSP present → small-bore chest tube (≤14F) preferred; attach to water seal/Heimlich valve, add suction if no re-expansion.
• Ambulatory one-way valves are emerging for select stable patients.

Special situations you can’t miss:
• Trauma: intervene by size thresholds (e.g., >20% on CXR or >35 mm on CT) and clinical status. Unstable or ventilated? Tube now. Consider antibiotics before placement and warm-saline irrigation to reduce re-interventions.
• ICU/ventilated: low threshold to drain occult PTX. Persistent air leak or non-expansion → early surgery (day 3–5).
• Tension: needle decompression → definitive tube, monitor for re-expansion edema.

Complications & tech that help:
• Persistent air leak, non-expansion, recurrence → surgical consult.
• Digital air-leak monitoring can shorten tube time and LOS; adoption varies.
• Invasive strategies carry more pain, infection, device issues—pick the lightest touch that works.

Recurrence & prevention plays:
• SSP has higher recurrence and morbidity—lean earlier to recurrence prevention.
• Options: VATS bullectomy + mechanical/talc pleurodesis (lowest recurrence), or chemical pleurodesis via tube if not surgical.
• Smoking cessation is non-negotiable.

What we still don’t know (and what we discuss):
• Optimal SSP pathways, standardized size definitions, and who truly benefits from ambulatory devices/outpatient care.
• How to best integrate digital air-leak monitoring into everyday practice.

We close with a simple ward-ready pathway:

1. Stability check → treat tension immediately.

2. Image smart (CXR → POCUS → CT when needed).

3. Stable PSP, low symptoms? Consider conservative care with clear follow-up.

4. If symptoms/size/SSP: aspiration → small-bore tube → suction if needed.

5. Trauma or vents: tube early; involve surgery by day 3–5 if leak persists.

6. Plan recurrence prevention before discharge (especially SSP).

7. Educate, mobilize smoking cessation, and schedule objective follow-up imaging.

Bottom line: Prioritize stability, use size + symptoms over labels, prefer small-bore and conservative strategies when safe, move fast for tension/vented patients, and prevent the next hit—especially in SSP.