Respiratory medicine for MRCPI Part 1

A 26-year-old man presents with sudden right-sided pleuritic chest pain and breathlessness. He is tall and thin and smokes. Chest radiograph shows a right-sided pneumothorax with a 3 cm rim at the level of the hilum. He is haemodynamically stable and not significantly breathless. What is the most appropriate management?

1. Urgent video-assisted thoracoscopic surgery with pleurodesis Wrong for a first episode. Surgery is considered for recurrence, persistent air leak, bilateral disease, or high-risk occupations.
2. Discharge with no follow-up and simple analgesia Wrong. Whatever the management route, he needs follow-up imaging, smoking cessation advice, and counselling about flying and diving.
3. Immediate intercostal chest drain in all cases with a rim over 2 cm Outdated as an absolute rule. Size still informs the decision, but a rigid size threshold mandating a drain in an asymptomatic patient exposes them to a procedure with real complications.
4. Needle decompression in the second intercostal space, mid-clavicular line Wrong. That is the emergency manoeuvre for a TENSION pneumothorax, which is a clinical diagnosis in a shocked patient with tracheal deviation.
5. Consider conservative management or needle aspiration, guided by symptoms rather than size alone correct Correct. Contemporary guidance has moved away from treating on size alone towards symptom-led management: a stable, minimally symptomatic patient with a primary spontaneous pneumothorax can be managed conservatively or with aspiration, with intercostal drainage reserved for significant symptoms or failure.

The point: Primary spontaneous pneumothorax is now managed by symptoms rather than by a millimetre threshold. Smoking is the dominant modifiable risk factor for recurrence. Diving is permanently contraindicated unless definitive surgery has been performed.

Source: BTS clinical statement on pleural disease — pneumothorax British Thoracic Society · tier 2, specialty society or college