Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Managing Pneumothorax Safely Outside Hospital

  Outpatient management of pneumothorax is increasingly relevant when a patient is clinically stable, has reliable support, and can access prompt reassessment. The approach is different from simply discharging someone with a small pneumothorax: it requires risk assessment, a defined treatment plan, documented safety-netting, and follow-up that is practical in the Australian healthcare system.

  The main categories are primary spontaneous pneumothorax, secondary spontaneous pneumothorax, traumatic pneumothorax, and iatrogenic pneumothorax after procedures such as central venous access or lung biopsy. Size alone should not determine management. Symptoms, physiology, underlying lung disease, recurrence risk, social circumstances, and access to care are equally important.

  Australian clinicians also need to account for geography and service availability. A patient living in inner Melbourne may have rapid access to emergency imaging, while someone in regional Queensland, Western Australia, or the Northern Territory may face a long transfer. Local respiratory, emergency, radiology, and thoracic surgery pathways should therefore be built into every outpatient plan.

  Selecting Patients For Ambulatory Care

  Outpatient care is generally most suitable for a haemodynamically stable patient with no evidence of tension pneumothorax, manageable breathlessness, acceptable oxygenation, and no major clinical deterioration. The patient should be able to understand instructions, use a drainage device if provided, return for review, and contact the service at any time.

  A small, minimally symptomatic primary spontaneous pneumothorax may be managed with observation and early review. For a larger or symptomatic pneumothorax, an ambulatory one-way valve device can permit treatment without prolonged admission when local expertise and follow-up are available. This decision should be based on clinical status rather than a radiographic measurement alone.

  Secondary spontaneous pneumothorax requires greater caution because chronic obstructive pulmonary disease, pulmonary fibrosis, cystic lung disease, malignancy, or infection can reduce physiological reserve. In many such cases, hospital observation or specialist input is safer, particularly when the patient is older, hypoxic, immunocompromised, or has significant comorbidities.

  Initial Assessment And Stabilisation

  Assessment begins with airway, breathing, circulation, respiratory rate, oxygen saturation, work of breathing, chest pain, mental state, and haemodynamic status. Sudden deterioration, severe respiratory distress, hypotension, tracheal deviation, or distended neck veins should raise concern for tension pneumothorax and requires immediate emergency treatment rather than outpatient planning.

  A chest X-ray is commonly used to confirm and monitor pneumothorax, while ultrasound can support rapid assessment when trained operators are available. CT is reserved for selected cases, such as uncertain diagnosis, suspected underlying disease, complex trauma, or planning for specialist intervention. Repeated imaging should answer a clinical question rather than follow a rigid schedule.

  Analgesia, smoking cessation advice, and treatment of contributing conditions are part of initial care. Supplemental oxygen may be indicated for hypoxaemia, but it should not substitute for drainage when intervention is clinically required. Avoid routine high-flow oxygen in patients at risk of hypercapnic respiratory failure unless it is carefully monitored.

  Observation, Aspiration, And Drainage

  Conservative observation can be appropriate for stable, minimally symptomatic patients, with a clear plan for reassessment. Needle aspiration may provide a less invasive alternative to intercostal catheter drainage in selected spontaneous pneumothoraces, although local protocols, clinician skill, and the likelihood of success matter.

  Ambulatory drainage usually involves a small-bore catheter connected to a one-way valve. The device allows pleural air to escape while limiting re-entry, potentially enabling mobilisation and discharge. Before leaving, clinicians should confirm that the system is functioning, the catheter is secure, pain is controlled, and the patient can identify a leak, blockage, dislodgement, or worsening symptoms.

  A chest drain should not be removed or clamped casually in the community. Removal requires clinical assessment and, where appropriate, imaging that confirms adequate lung re-expansion. Persistent air leak, increasing pneumothorax, worsening pain, or failure to improve should prompt escalation to respiratory or thoracic surgical services.

  Follow-Up And Safety-Netting

  An outpatient pathway should specify who reviews the patient, where that review occurs, and when imaging is performed. A common approach is review within 24 to 48 hours, followed by further assessment until symptoms resolve and the lung remains expanded. The exact interval depends on the treatment method, symptoms, imaging, and local policy.

  Written advice should use plain language and include urgent warning signs: increasing shortness of breath, chest pain, faintness, blue lips, confusion, fever, or a malfunctioning drainage device. The patient should know whether to call 000, attend the nearest emergency department, or contact the treating respiratory service.

  Follow-up must reflect Australian travel distances and service patterns. A patient discharged from a metropolitan emergency department may be reviewed through a hospital ambulatory clinic, whereas a person in rural New South Wales may need coordination with a local GP, Aboriginal Community Controlled Health Service, district hospital, and retrieval network.

  Activities, Air Travel, And Recurrence

  Patients should avoid strenuous exertion while symptomatic and should receive individual advice about work, driving, and exercise. Air travel should be postponed until the pneumothorax has resolved and an appropriate interval has passed after radiographic resolution, because cabin pressure changes can enlarge residual pleural air. The treating specialist should document travel advice clearly.

  Scuba diving carries a substantial recurrence risk and should generally be avoided after spontaneous pneumothorax unless a specialist assessment and definitive preventive procedure support a safe return. Smoking and vaping increase recurrence risk, so cessation support should be offered rather than treated as an afterthought.

  Recurrence is common enough to require planned counselling. Referral to a respiratory physician or thoracic surgeon may be appropriate after recurrent pneumothorax, persistent air leak, bilateral disease, high-risk occupation, or a first episode associated with significant underlying lung pathology.

  Practical Safety Checks

  Before discharge, the clinical team should confirm:

  • Stable observations and controlled symptoms
  • A documented diagnosis and treatment strategy
  • Functioning equipment with secure dressing, if a drain is present
  • A booked review and imaging plan
  • Written emergency instructions and reliable transport

  Communication should include the patient’s GP and any service responsible for the next assessment. In Australia, electronic discharge summaries can reduce gaps between public hospitals, private clinics, community providers, and regional services, particularly when the patient crosses state or health-district boundaries.

  Matching Care To Risk

  Clinical situation	Usually suitable pathway	Key safeguards
  Small, stable primary spontaneous pneumothorax	Observation with early review	Reliable patient, clear return precautions, repeat assessment
  Symptomatic but stable primary pneumothorax	Aspiration or ambulatory one-way valve	Trained clinician, device education, prompt imaging
  Secondary pneumothorax with lung disease	Specialist-led care, often hospital-based	Lower threshold for admission and respiratory consultation
  Traumatic or iatrogenic pneumothorax	Cause-specific observation or drainage	Assess associated injuries and procedural complications
  Tension features or physiological instability	Immediate emergency treatment	Do not delay decompression for outpatient imaging or referral
  Persistent air leak or failed ambulatory treatment	Hospital review and thoracic/respiratory input	Consider intervention and investigation for underlying disease

  A safe discharge decision is therefore a systems decision as well as a clinical one. The treatment may be delivered outside hospital, but responsibility for review, escalation, and continuity must remain explicit.

  A Defined Next Step

  For each stable patient being considered for outpatient pneumothorax care, record four items before discharge: the risk category, the treatment provided, the exact time and location of follow-up imaging, and the emergency contact pathway. The immediate next step is to arrange that review before the patient leaves the facility.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)