A tall, thin 19-year-old smoker develops sudden right-sided pleuritic pain and mild breathlessness. CXR shows a rim of air measuring 18 mm between the lung edge and chest wall at the hilum level. He is hemodynamically stable with SpO2 96%. What is the most appropriate initial management?
- A Immediate thoracotomy with pleurodesis
- B Needle aspiration, proceeding to chest drain if unsuccessful ✓
- C Observation with supplemental oxygen alone
- D High-flow non-invasive ventilation
Correct answer: B. Needle aspiration, proceeding to chest drain if unsuccessful
Explanation
This is a large primary spontaneous pneumothorax by BTS criteria (rim greater than 2 cm at the hilum) in a symptomatic patient, so intervention is required. Needle aspiration is recommended first for primary spontaneous pneumothorax, with chest drain reserved for failure of aspiration or recurrence. Observation suits only small asymptomatic pneumothoraces, NIV worsens air leak, and surgery is for persistent leak or recurrence, not the first episode.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.