What is the typical management for a large primary spontaneous pneumothorax in a stable patient?

• A. Chest tube thoracostomy or needle aspiration; watchful waiting for small, stable pneumothoraces.
• B. Immediate thoracotomy for all cases.
• C. Oxygen only.
• D. Medication with steroids.

Answer: (A)

When a large primary spontaneous pneumothorax occurs in a stable patient, the goal is to remove the air from the pleural space to allow the lung to re-expand. The preferred approaches are either needle aspiration or chest tube thoracostomy. Needle aspiration is less invasive and can be done for a stable, large pneumothorax to evacuate air quickly. If air continues to leak, if the pneumothorax is very large, or if needle aspiration fails, placing a chest tube provides continuous drainage and ensures re-expansion with suction or an underwater seal. Observation with supplemental oxygen is more appropriate for small, stable pneumothoraces. Immediate thoracotomy isn’t indicated in a stable large PSP and is considered only for persistent air leak or failed less invasive treatments. Steroids have no role in managing a pneumothorax.