What causes pneumothorax in the ICU, and which ones need a chest drain?

Published 2026-09-07 · Updated 2026-09-07 · Last checked against sources 2026-09-07

Before I looked it up

In the ICU, pneumothorax is one of the fairly common(?) diseases. In my case I do PCD (percutaneous catheter drainage) insertion quite a lot to remove pleural effusion, and having often experienced a pneumothorax forming when the effusion is drained in an instant at the start, at present, unless the O2 demand is extremely high, I drain slowly. I looked up and organised the various causes of pneumothorax, the treatment methods, and the latest recommendations.

What I found

The note I started from was about pneumothorax in general — who gets it, how often it comes back, when to operate. Going back to it from the ICU, three things stood out.

• Most ICU pneumothoraces are iatrogenic. In a prospective cohort of 3,430 ICU patients the cumulative incidence was 3.0% by day 30 (1.4% by day 5). Of 94 cases, 42 were barotrauma and 52 were procedures. Risk factors: ARDS (HR 5.3), body weight under 80 kg (2.4), central venous or pulmonary artery catheter (1.7), cardiogenic pulmonary oedema (2.0). A pneumothorax carried a 2.6-fold excess risk of death.
• Most pneumothoraces seen after draining an effusion are not a punctured lung. They are a lung that will not re-expand — non-expandable lung, pneumothorax ex vacuo. In 401 ultrasound-guided thoracenteses there was one pneumothorax from lung puncture and eight drainage-related ones, and all eight had radiographic signs of a lung that could not expand. Watching symptoms or pleural pressure does not prevent them, and they rarely need treatment.
• Drain slowly, no vacuum, 1.5 L per attempt, stop at symptoms — the 2023 BTS clinical statement on pleural procedures. Routine pleural manometry did not reduce pain or complications in a randomised trial. In that same trial, though, 10% of the symptom-only group had an asymptomatic ex vacuo pneumothorax and the manometry group had none.

The rest of what I found, in order.

• Ventilator barotrauma: 2.9% of 5,183 ventilated patients. ARDS 6.5%, interstitial lung disease 10.0%, asthma 6.3%. Ventilator settings did not differ between patients with and without barotrauma — the underlying lung decides.
• Central lines: pneumothorax needing a chest tube in 1.5% of subclavian versus 0.5% of jugular insertions in a randomised trial of 3,471 catheters. Ultrasound guidance for the internal jugular cuts total complications by 71%.
• Do not trust a supine chest X-ray. Supine film sensitivity 50%, ultrasound 91% (specificity 98%). CT is the reference.
• A pneumothorax in a ventilated patient gets a chest drain, whatever the cause — tension and bronchopleural fistula risk (BTS 2023). Large-bore if the air leak is big. An occult traumatic pneumothorax can be observed if the patient is stable and ventilation is short, but 40% of those ventilated five days or more end up drained (OPTICC).
• Needle decompression for tension: the second intercostal space at the midclavicular line fails 38% of the time with a 5 cm catheter; the fourth or fifth space at the anterior axillary line fails 13%. ATLS 10th edition moved adults to the fifth space.
• Spontaneous pneumothorax (the part the original note covered): recurrence after a first primary episode is about 30%, mostly in the first year. Smoking raises the risk of a first episode 22-fold in men and 9-fold in women; quitting cuts recurrence to a quarter. Second ipsilateral or first contralateral episode: consider surgery. Recurrence after surgery is very low, slightly higher with VATS than thoracotomy. Size is no longer an indication for intervention (BTS 2023). Flying: 7 days after the X-ray shows full resolution. Scuba: permanently discouraged unless definitive surgery has been done.

What I was reading

Three documents: the BTS Guideline for pleural disease 2023 (management of spontaneous pneumothorax), the BTS Clinical Statement on pleural procedures 2023 (aspiration, drains, drainage rate), and the joint ERS/EACTS/ESTS 2024 guideline on spontaneous pneumothorax. One thing to know before anything else: the 2023 BTS guideline explicitly excludes traumatic and iatrogenic pneumothorax from its evidence review. So the ICU parts below come from the procedures statement and from individual trials and cohorts, not from a guideline, and I have marked the strength of evidence in each section.

The note I started from cited “BTS guidelines” and an “ACCP consensus statement” without editions. The BTS 2023 document replaced the 2010 guideline, and the ACCP statement is a Delphi consensus from 2001. What follows is what I read in September 2026.

1. Where pneumothorax comes from in the ICU

Evidence: one prospective ICU cohort (twelve French ICUs, the OUTCOMEREA group) and one international ventilation cohort.

A pneumothorax is air in the pleural space with collapse of the lung. The distribution of causes on a ward or in an emergency department is not the distribution in an ICU.

Iatrogenic — the majority in the ICU

• Procedures: central venous and pulmonary artery catheters, thoracentesis and percutaneous catheter drainage, transbronchial biopsy, bronchoscopy.
• Barotrauma: alveolar rupture under positive-pressure ventilation — pneumothorax, pneumomediastinum, subcutaneous emphysema.
• In the 3,430-patient cohort, 94 iatrogenic pneumothoraces within 30 days: 42 barotrauma, 52 procedural. Cumulative incidence 1.4% at day 5, 3.0% at day 30.
• Risk factors (hazard ratios): ARDS 5.3 (2.6–11) · history of AIDS 2.8 · body weight under 80 kg 2.4 · inotropes in the first 24 hours 2.1 · cardiogenic pulmonary oedema 2.0 · central venous or pulmonary artery catheter 1.7 (1.0–2.7).
• Excess risk of death in patients who developed one: 2.6 (1.3–4.9).

Secondary spontaneous — underlying lung disease

• COPD (also the commonest comorbidity in Korean data), tuberculosis, pneumonia, cystic fibrosis, Marfan syndrome, lung cancer, interstitial lung disease.
• BTS 2023 treats anyone over 50 with a smoking history as secondary even without a known lung disease, because this group responds differently to needle aspiration than young non-smokers. In English national admission data, 60.8% of spontaneous pneumothorax admissions had chronic lung disease.

Traumatic — blunt or penetrating. Trauma CT frequently finds an occult pneumothorax that the plain film missed, and the problem starts when that patient goes onto positive-pressure ventilation (section 6).

Primary spontaneous — a disease of people outside the ICU. Tall, thin young men; rupture of blebs or bullae on the lung surface. Smoking multiplies the risk of a first episode 22-fold in men and 9-fold in women, with a clear dose-response. The male to female ratio is about 6:1 in US data and 4–10:1 in Korea, where prevalence peaks at age 15–19. “Primary” does not mean the lung is normal — most have emphysema-like changes on CT (BTS 2023). Recurrence and surgery are in section 8.

2. Pneumothorax after draining an effusion — punctured lung, or a lung that will not expand?

Evidence: one meta-analysis, one large single-centre cohort, one mechanistic series, one randomised trial, and the 2023 BTS procedures statement.

How often

• Meta-analysis of 24 studies and 6,605 thoracenteses: pneumothorax in 6.0% (95% CI 4.6–7.8), and 34.1% of those needed a chest tube. With experienced operators, ultrasound guidance 3.9% versus 8.5% without (p=0.04).
• A single US centre over 12 years, 9,320 inpatient thoracenteses by a procedure service with ultrasound: pneumothorax 57 (0.61%), re-expansion pulmonary oedema 10 (0.1%), bleeding 17 (0.18%). Pneumothorax was associated with removal of more than 1,500 mL (p<0.0001), unilateral procedures, and more than one needle pass (p=0.001).
• What raises the risk: therapeutic rather than diagnostic tap (OR 2.6, 1.8–3.8) · symptoms during the procedure (OR 26.6) · mechanical ventilation (OR 4.0, 0.95–16.8 — not significant, but the direction is consistent) · low body weight.

Most of them are not punctures — three mechanisms

The BTS 2023 procedures statement divides a pneumothorax on the post-aspiration film into three.

1. True iatrogenic pneumothorax — the needle punctured the visceral pleura, or the visceral pleura sheared as the lung re-expanded (an alveolar or bronchopleural fistula).
2. Non-expandable lung (pneumothorax ex vacuo) — a thickened visceral pleural rind stops the lung from re-expanding, and air fills the space the fluid left.
3. Air entrained through the device during the procedure.

The statement then says that the true incidence of clinically significant post-procedure pneumothorax is hard to establish, because many small pneumothoraces on the film are entrained air or non-expandable lung and are of no clinical consequence.

Heidecker 2006 — 401 ultrasound-guided thoracenteses, most with pleural manometry: one pneumothorax from lung puncture; eight drainage-related pneumothoraces, and all eight had radiographic evidence of a lung that could not expand (a visceral pleural peel, lobar atelectasis, a basal pneumothorax, or pneumothorax with ipsilateral shift). Four of the eight had abnormal pleural elastance, and none had a pleural pressure below −25 cmH₂O. The authors’ conclusions:

• These pneumothoraces cannot be prevented by monitoring for symptoms or for excessively negative pressure.
• The likely mechanism is a transient, pressure-dependent parenchymal-pleural fistula from uneven stress on the visceral pleura when the lung cannot conform to the shape of the chest during large-volume drainage.
• They rarely require treatment. They account for the vast majority of post-thoracentesis pneumothoraces in a procedure service.

Rate and volume — what is actually specified

The 2023 BTS procedures statement, clinical practice points for aspiration:

• Thoracic ultrasound is mandatory.
• Therapeutic aspiration is done slowly — manual syringe aspiration or gravity drainage. No vacuum bottles, no wall suction.
• A maximum of 1.5 L in one attempt. Stop earlier if symptoms develop — chest tightness, pain, persistent cough, worsening breathlessness.
• Routine pleural manometry does not reduce the risk of large-volume aspiration.
• The reasoning behind 1.5 L is stated: re-expansion pulmonary oedema is rare but can be fatal, so the guidance is deliberately conservative, and large-volume aspiration also appears to raise the risk of post-procedure pneumothorax. Larger volumes can be taken with expert monitoring.

The manometry trial (Lentz 2019, 124 patients) — drainage guided by symptoms alone versus symptoms plus manometry (stop if end-expiratory pressure fell below −20 cmH₂O or dropped more than 10 between readings). The primary outcome, chest discomfort, was no different (2.4 mm on a 100 mm scale, p=0.56). Asymptomatic pneumothorax ex vacuo occurred in 6 of 62 (10%) of the symptom-only group and none of the manometry group (p=0.01). No serious complications in either arm. The authors concluded against routine manometry, and BTS adopted that — a 10% rate of asymptomatic ex vacuo pneumothorax that needs no treatment did not change the conclusion.

Re-expansion pulmonary oedema — the original reason for the 1.5 L rule

• Symptomatic re-expansion oedema occurs in under 1% in the largest series (BTS statement). Typically hypoxaemia and new diffuse alveolar infiltrates within an hour of the tap.
• Feller-Kopman 2007, 185 large-volume taps of 1 L or more: clinical re-expansion oedema in one patient (0.5%), radiographic only in four (2.2%). Not associated with the volume removed, the change in pleural pressure, elastance, or symptoms. The authors’ conclusion: the recommendation to stop at 1 L should be reconsidered; large effusions can be drained completely as long as chest discomfort or an end-expiratory pressure below −20 cmH₂O does not develop.
• Ault 2015, the 9,320-procedure series: 10 cases, and a dose-response relationship between volume removed and risk.
• So on whether volume matters, the data disagree. BTS kept 1.5 L knowing this — the background was a national patient-safety alert after 16 UK cases of re-expansion oedema in three years, including two deaths and one cardiac arrest.
• A drain placed for effusion is clamped promptly if the patient develops repetitive coughing or chest pain, regardless of volume (BTS statement). Pneumothorax drainage is the other way round: draining a large pneumothorax shows radiographic re-expansion oedema in up to a third of cases (mostly asymptomatic), but clamping a bubbling drain risks tension, so the rate is controlled by not applying suction at the initial drainage.

3. The ventilator — barotrauma

Evidence: one international prospective cohort (361 ICUs in 20 countries) and the ICU cohort above.

• Of 5,183 patients ventilated for more than 12 hours, barotrauma in 154 (2.9%).
• By reason for ventilation: interstitial lung disease 10.0% · ARDS 6.5% · asthma 6.3% · pneumonia 4.2% · COPD 2.9%.
• Patients with and without barotrauma did not differ in any ventilator parameter — tidal volume or airway pressure. The independent risk factors were all in the lung: ILD RR 4.23 · asthma 2.58 · ARDS as the reason for ventilation 2.70 · ARDS developing during ventilation 2.53.
• Mortality with barotrauma 51.4% versus 39.2% (p=0.04), and longer ICU stay.
• This cohort dates from an era that already limited tidal volume and pressure. What it says is not that lower settings would abolish barotrauma; it says the worse the underlying lung, the more it happens.

4. Central lines

Evidence: one randomised trial (3SITES) and one Cochrane meta-analysis.

• 3SITES, adult ICUs, 3,471 catheters: pneumothorax requiring a chest tube in 13 subclavian insertions (1.5%) and 4 jugular (0.5%), none applicable to femoral. Bloodstream infection and symptomatic thrombosis, on the other hand, were lowest with subclavian (femoral HR 3.5, jugular 2.1 against subclavian). Site is not chosen on pneumothorax alone.
• Ultrasound guidance for the internal jugular (Cochrane, 35 trials, 5,108 participants): total complications down 71% (RR 0.29), arterial puncture down 72%, first-attempt success up 57%. Evidence quality mostly low.
• In the ICU cohort, central venous or pulmonary artery catheter insertion carried a pneumothorax HR of 1.7 (1.0–2.7).

5. Diagnosis — do not trust a supine film

Evidence: one meta-analysis of eight studies and 1,048 patients. Reference standard CT, or air on chest tube placement.

• Supine chest radiograph: sensitivity 50.2% (43.5–57.0), specificity 99.4%.
• Ultrasound (absent lung sliding, absent comet tails): sensitivity 90.9% (86.5–93.9), specificity 98.2%.
• Critically ill patients are mostly supine. Air goes anterior and inferior, the apical pleural line does not appear, and the film misses half. If you suspect it, put the ultrasound on first; confirmation, size, and surgical planning are CT.
• The BTS procedures statement: ultrasound is not required to site a drain for pneumothorax itself (the film is enough), but it helps with a loculated pneumothorax or a tethered lung.

6. What gets drained — ICU version

Strength: BTS 2023 procedures statement practice point (ventilated patients) · two randomised trials (OPTICC) · observational series (ex vacuo) · BTS 2023 guideline, conditional (spontaneous).

Occult traumatic pneumothorax — what OPTICC showed

• OPTICC 2013, 90 severely injured ventilated patients (mean ISS 33): chest tube versus observation. The composite respiratory-distress outcome had RR 0.71 (0.40–1.27) — no difference. 20% of the observed group were drained later, and one (2%) developed tension, treated with an urgent tube without sequelae. In the drainage group 15% had drain complications and another 15% had a suboptimally positioned tube.
• Final report 2021, 75 observed versus 67 drained: respiratory distress 38% versus 25% (p=0.14, power 0.38). A quarter of the observed group failed, 40% if ventilated more than 5 days. 23% of the drained group had complications or an ineffective drain.
• The authors’ conclusion: stable patients on short-term positive-pressure ventilation can be observed cautiously with rescue drainage at hand; where prolonged ventilation is expected, consider drainage by an expert. So “observe an occult pneumothorax” and “drain a pneumothorax on a ventilator” are not in conflict — the duration of ventilation is the fork.

Spontaneous pneumothorax, first episode — the size rule is over

One sentence from BTS 2023: size of pneumothorax is no longer an indication for invasive management (although it does dictate the safety of conducting an intervention), and the use of chest drains is centred on patients with high-risk characteristics. The rule in my original note — under 2 cm observe, 2 to 3 cm consider aspiration, over 3 cm drain — mixed the 2 cm threshold from BTS 2010 with the 3 cm threshold from ACCP 2001, and neither is current.

• PSP trial (Brown 2020): 316 patients aged 14–50 with a first moderate-to-large primary spontaneous pneumothorax, immediate intervention versus conservative observation. Re-expansion within 8 weeks 98.5% versus 94.4%, inside the non-inferiority margin. 84.6% of the conservative group never had an intervention, and serious adverse events and recurrence were lower. But a sensitivity analysis counting missing data as failure fell outside the margin — the authors themselves called it modest evidence.
• RAMPP (Hallifax 2020): 236 symptomatic primary pneumothoraces, ambulatory valve device versus standard care (aspiration or drain). Total hospital stay over 30 days 0 days versus 4. All 14 serious adverse events were in the ambulatory arm.

7. Emergency decompression — the site moved

Evidence: one meta-analysis (15 studies of chest wall thickness, 13 of failure rate) and one cadaver study. The guideline is ATLS 10th edition.

• The traditional second intercostal space at the midclavicular line has a mean chest wall thickness of 42.8 mm there, and a 5 cm catheter fails 38% of the time (24–54). The fourth or fifth space at the anterior axillary line is 34.3 mm, failure 13% (8–22). In 80 cadaver insertions, the fifth space at the midaxillary line reached the pleural cavity 100% of the time versus 58% at the second.
• ATLS 10th edition (2018) moved the adult site to the fifth intercostal space, anterior axillary line (children stay at the second space, midclavicular). The “2nd ICS, MCL” in my note is not the wrong place so much as the place that fails most.
• A chest drain follows decompression. On a ventilator it is a chest drain from the start (section 6).

8. Recurrence and surgery in spontaneous pneumothorax — the part the original note covered

Evidence: meta-analysis (Walker 2018, 29 studies, 13,548 patients, I² 94%) · two national cohorts (England, Korea) · two surgical meta-analyses · BTS 2023 good practice points.

Recurrence rates

After a first primary spontaneous pneumothorax:  about 30%  (meta-analysis 29.0% at 1 year, 32.1% overall; individual studies 20–60%)
Recurrence within 5 years:                        about 25%  (English national admissions 1968 to 2016; men 25.5%, women 26.0%)
Korea, under 35:                                  20.3%      (national insurance data 2002 to 2020, young patients without comorbidity)
After a second episode:                           higher — no primary source found for a figure

• Recurrence clusters in the first year. In Korean data more than 70% of recurrences were within a year. Contralateral occurrence 14.3% (231 Taiwanese patients, mean follow-up 92 months).
• The “60–80% after a second episode” in my original note has no source I could find, so it is gone. The indication for surgery after a second episode does not depend on that number.
• Risk factors: female sex (OR 3.03), tall men, continued smoking (OR 0.26 for recurrence after quitting — a quarter of the risk), bullae on CT (dose-response from 1 cm), low body weight plus contralateral blebs (contralateral recurrence OR 5.3). “Incomplete initial treatment” was in my note as a risk factor and has no support — initial treatment and size were unrelated to recurrence (Sadikot 1997), and BTS 2023 says recurrence appears if anything higher after a chest drain than after conservative management.
• Five-year readmission in English data: 39.2% in men aged 15–34 with chronic lung disease, 19.6% in men over 65 without.

Who gets surgery (BTS 2023 good practice points)

• Second ipsilateral or first contralateral pneumothorax — consider surgery.
• First episode in an at-risk profession (pilots, divers, military), a first episode presenting with tension, persistent air leak (5–7 days), synchronous bilateral, spontaneous haemothorax — consider.
• BTS 2023 could not make a formal recommendation on early surgery after a first episode for lack of evidence. ERS 2024 gives a conditional recommendation for patients who prioritise recurrence prevention. In the first-episode trial (Olesen 2018, 181 patients), adding VATS reduced recurrence, especially with bullae of 1 cm or more (p=0.014).
• In Korean insurance data on patients under 35, 25.6% had surgery as their first treatment, and the surgical group had a higher five-year recurrence (23.7% versus 7.9%) — claims data with obvious confounding by indication, not to be read as surgery causing recurrence.
• Chemical pleurodesis: BTS 2023 suggests it for recurrence prevention in secondary pneumothorax (severe COPD, where a pneumothorax decompensates the patient). In primary pneumothorax, one trial of intrapleural minocycline 300 mg after aspiration cut one-year recurrence from 49.1% to 29.2% (Chen 2013).

Recurrence after surgery

• “Very low” (BTS 2023). Ipsilateral recurrence after VATS under 5%.
• VATS versus thoracotomy: with the same pleurodesis, VATS carried 4.7 times the recurrence risk (RR 4.73, 2.70–8.29 — Barker 2007). Thoracotomy with pleurodesis is what BTS suggests for the lowest recurrence in high-risk occupations. Stay, pain, and complications favour VATS.
• Pleurectomy versus pleural abrasion: no difference in recurrence (RR 1.34, 0.94–1.92 — Chang 2023). My note had pleurectomy as “the most effective” — there is no evidence for that.

Discharge advice

• Flying: no commercial flights with an unresolved closed pneumothorax. 7 days after the X-ray confirms full resolution — the 7 days are to exclude early recurrence. The “2 to 6 weeks” in my note appears in no edition.
• Scuba diving: permanently discouraged unless a very secure definitive procedure such as surgical pleurectomy has been done.
• Follow-up X-ray at 2 to 4 weeks after conservative management or aspiration. Return immediately with chest pain or breathlessness. Stop smoking.

What I take from it

1. Three per cent of ICU patients get an iatrogenic pneumothorax, and half of those are procedures. Know the number before the procedure.
2. A pneumothorax after draining an effusion is usually a lung that will not expand, not a lung you punctured. Symptoms and pressure do not prevent it, and in a spontaneously breathing patient it is usually watched.
3. Aspirate slowly, no vacuum, 1.5 L, stop at symptoms. Manometry did not reduce pain — though it did reduce asymptomatic ex vacuo pneumothorax.
4. A pneumothorax on a ventilator gets a drain. Even an occult one ends up drained in 40% once ventilation passes five days.
5. A supine film misses half. Ultrasound first.
6. Decompress at the fifth intercostal space. At the second space, midclavicular, one needle in three does not reach the pleura.
7. Spontaneous pneumothorax: about 30% recur, a second episode means surgery, fly 7 days after resolution, never dive. The era of deciding by size is over.
8. From inside a hospital — the recurrence pattern of pneumothorax patients can be seen in the EMR.

Sources

Guidelines and statements

• Roberts ME, Rahman NM, Maskell NA, et al.; BTS Pleural Guideline Development Group. British Thoracic Society Guideline for pleural disease. Thorax. 2023;78(Suppl 3):s1-s42. doi:10.1136/thorax-2022-219784 · PMID 37433578
• Asciak R, Bedawi EO, Bhatnagar R, et al. British Thoracic Society Clinical Statement on pleural procedures. Thorax. 2023;78(Suppl 3):s43-s68. doi:10.1136/thorax-2022-219371 · PMID 37433579
• Walker S, Hallifax R, Ricciardi S, et al. Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax. Eur Respir J. 2024;63(5):2300797. doi:10.1183/13993003.00797-2023 · PMID 38806203
• 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. doi:10.1136/thoraxjnl-2021-218110 · PMID 35228307
• MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(Suppl 2):ii18-31. doi:10.1136/thx.2010.136986 · PMID 20696690 — superseded by the 2023 guideline; the source of the 2 cm rule
• Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001;119(2):590-602. doi:10.1378/chest.119.2.590 · PMID 11171742 — the source of the 3 cm rule
• American College of Surgeons. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed. Chicago: ACS; 2018. — adult decompression site, fifth intercostal space, anterior axillary line

Pneumothorax in the ICU — epidemiology and iatrogenic causes

• de Lassence A, Timsit JF, Tafflet M, et al.; OUTCOMEREA Study Group. Pneumothorax in the intensive care unit: incidence, risk factors, and outcome. Anesthesiology. 2006;104(1):5-13. doi:10.1097/00000542-200601000-00003 · PMID 16394682
• Anzueto A, Frutos-Vivar F, Esteban A, et al. Incidence, risk factors and outcome of barotrauma in mechanically ventilated patients. Intensive Care Med. 2004;30(4):612-619. doi:10.1007/s00134-004-2187-7 · PMID 14991090
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• Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev. 2015;1(1):CD006962. doi:10.1002/14651858.CD006962.pub2 · PMID 25575244
• Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis. Chest. 2012;141(3):703-708. doi:10.1378/chest.11-0131 · PMID 21868468
• Kirkpatrick AW, Rizoli S, Ouellet JF, et al. Occult pneumothoraces in critical care: a prospective multicenter randomized controlled trial of pleural drainage for mechanically ventilated trauma patients with occult pneumothoraces. J Trauma Acute Care Surg. 2013;74(3):747-754. doi:10.1097/TA.0b013e3182827158 · PMID 23425731
• Clements TW, Sirois M, Parry N, et al. OPTICC: A multicentre trial of Occult Pneumothoraces subjected to mechanical ventilation: The final report. Am J Surg. 2021;221(6):1252-1258. doi:10.1016/j.amjsurg.2021.02.012 · PMID 33641940

Pneumothorax after pleural drainage, and re-expansion oedema

• Gordon CE, Feller-Kopman D, Balk EM, Smetana GW. Pneumothorax following thoracentesis: a systematic review and meta-analysis. Arch Intern Med. 2010;170(4):332-339. doi:10.1001/archinternmed.2009.548 · PMID 20177035
• Ault MJ, Rosen BT, Scher J, Feinglass J, Barsuk JH. Thoracentesis outcomes: a 12-year experience. Thorax. 2015;70(2):127-132. doi:10.1136/thoraxjnl-2014-206114 · PMID 25378543
• Heidecker J, Huggins JT, Sahn SA, Doelken P. Pathophysiology of pneumothorax following ultrasound-guided thoracentesis. Chest. 2006;130(4):1173-1184. PMID 17035453
• Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg. 2007;84(5):1656-1661. doi:10.1016/j.athoracsur.2007.06.038 · PMID 17954079
• Lentz RJ, Lerner AD, Pannu JK, et al. Routine monitoring with pleural manometry during therapeutic large-volume thoracentesis to prevent pleural-pressure-related complications: a multicentre, single-blind randomised controlled trial. Lancet Respir Med. 2019;7(5):447-455. doi:10.1016/S2213-2600(18)30421-1 · PMID 30772283

Spontaneous pneumothorax — trials

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• 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. doi:10.1016/S0140-6736(20)31043-6 · PMID 32622394
• Chen JS, Chan WK, Tsai KT, et al. Simple aspiration and drainage and intrapleural minocycline pleurodesis versus simple aspiration and drainage for the initial treatment of primary spontaneous pneumothorax: an open-label, parallel-group, prospective, randomised, controlled trial. Lancet. 2013;381(9874):1277-1282. doi:10.1016/S0140-6736(12)62170-9 · PMID 23489754
• Olesen WH, Katballe N, Sindby JE, et al. Surgical treatment versus conventional chest tube drainage in primary spontaneous pneumothorax: a randomized controlled trial. Eur J Cardiothorac Surg. 2018;54(1):113-121. doi:10.1093/ejcts/ezy003 · PMID 29509892

Spontaneous pneumothorax — recurrence and epidemiology

• 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. doi:10.1183/13993003.00864-2018 · PMID 30002105
• Hallifax RJ, Goldacre R, Landray MJ, Rahman NM, Goldacre MJ. Trends in the Incidence and Recurrence of Inpatient-Treated Spontaneous Pneumothorax, 1968-2016. JAMA. 2018;320(14):1471-1480. doi:10.1001/jama.2018.14299 · PMID 30304427
• Sadikot RT, Greene T, Meadows K, Arnold AG. Recurrence of primary spontaneous pneumothorax. Thorax. 1997;52(9):805-809. doi:10.1136/thx.52.9.805 · PMID 9371212
• Huang TW, Lee SC, Cheng YL, et al. Contralateral recurrence of primary spontaneous pneumothorax. Chest. 2007;132(4):1146-1150. doi:10.1378/chest.06-2772 · PMID 17550937
• Bense L, Eklund G, Wiman LG. Smoking and the increased risk of contracting spontaneous pneumothorax. Chest. 1987;92(6):1009-1012. doi:10.1378/chest.92.6.1009 · PMID 3677805
• Melton LJ 3rd, Hepper NG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950 to 1974. Am Rev Respir Dis. 1979;120(6):1379-1382. PMID 517861
• Kim D, Jung B, Jang BH, Chung SH, Lee YJ, Ha IH. Epidemiology and medical service use for spontaneous pneumothorax: a 12-year study using nationwide cohort data in Korea. BMJ Open. 2019;9(10):e028624. doi:10.1136/bmjopen-2018-028624 · PMID 31662355
• Yi E, Park JE, Chung JH, et al. Trends in recurrence of primary spontaneous pneumothorax in young population after treatment for first episode based on a nationwide population data. Sci Rep. 2023;13(1):13478. doi:10.1038/s41598-023-39717-y · PMID 37596298

Surgery and decompression

• Barker A, Maratos EC, Edmonds L, Lim E. Recurrence rates of video-assisted thoracoscopic versus open surgery in the prevention of recurrent pneumothoraces: a systematic review of randomised and non-randomised trials. Lancet. 2007;370(9584):329-335. doi:10.1016/S0140-6736(07)61163-5 · PMID 17662881
• Chang J, Ratnaraj V, Fu V, et al. Pleural abrasion versus apical pleurectomy for primary spontaneous pneumothorax: a systematic review and meta-analysis. J Cardiothorac Surg. 2023;18(1):105. doi:10.1186/s13019-023-02207-3 · PMID 37024894
• Laan DV, Vu TD, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2016;47(4):797-804. doi:10.1016/j.injury.2015.11.045 · PMID 26724173
• Inaba K, Branco BC, Eckstein M, et al. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma. 2011;71(5):1099-1103. doi:10.1097/TA.0b013e31822d9618 · PMID 22071914