A tall, thin 19-year-old man develops sudden right-sided pleuritic pain and dyspnea. Chest radiograph shows complete collapse of the right lung with a rim of air exceeding 2 cm at the hilum. He is haemodynamically stable with oxygen saturation of 94% on room air. What is the recommended initial management?

• A Observation with high-flow oxygen alone
• B Ambulatory device insertion with follow-up in clinic
• C Immediate thoracoscopic bullectomy and pleurodesis
• D Needle aspiration of the pneumothorax ✓

Explanation

This is a large primary spontaneous pneumothorax (rim greater than 2 cm) in a stable young patient. Guideline practice places needle aspiration as the first intervention for such patients, proceeding to chest tube drainage only if aspiration fails or re-expansion is incomplete. Observation with oxygen suits small asymptomatic pneumothoraces, ambulatory devices suit selected stable patients in specialised settings, and surgery is reserved for recurrence or persistent air leak, not first presentation.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.