A 22-year-old tall, thin man develops sudden right-sided pleuritic chest pain while resting. He is haemodynamically stable and reports no breathlessness. Chest radiograph shows a visible rim of air measuring 1.2 cm at the level of the hilum with partial lung collapse. There is no prior lung disease. What is the most appropriate initial management?
- A Observation with oxygen, review imaging at 4 to 6 hours, and discharge with advice ✓
- B Immediate intercostal chest drain insertion
- C Urgent video-assisted thoracoscopic bullectomy and pleurodesis
- D Needle decompression in the second intercostal space midclavicular line
Correct answer: A. Observation with oxygen, review imaging at 4 to 6 hours, and discharge with advice
Explanation
This is a small primary spontaneous pneumothorax (rim under 2 cm at the hilum) in a stable, non-breathless patient. Guidelines allow conservative management with observation, supplemental oxygen to speed reabsorption, repeat imaging to exclude enlargement, and clear return precautions; most resolve spontaneously. Chest drains are reserved for large, enlarging, or secondary pneumothoraces, and surgery is for recurrence or persistent air leak. Needle decompression is the emergency treatment of tension pneumothorax, which this patient does not have given his stability.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.