Pneumothorax nursing: updated ATLS decompression site and chest tube care

A pneumothorax is the presence of air in the pleural space – the normally airtight cavity between the visceral and parietal pleura. When air enters, the negative intrapleural pressure that holds the lung expanded is disrupted, and the lung collapses fully or partially. Pneumothorax ranges from a minor incidental finding to an immediately life-threatening emergency requiring intervention within minutes.

For nursing students, three priorities stand out: recognizing the clinical difference between spontaneous, traumatic, and tension pneumothorax; understanding why tension pneumothorax demands intervention before any imaging; and managing chest tube drainage systems safely. This reference covers all three, along with pathophysiology, assessment findings, chest tube care, patient education, and NCLEX-style practice questions.

Pair this page with the pneumonia nursing reference, pleural effusion nursing reference, pulmonary embolism nursing reference, and ARDS nursing reference – all four conditions can coexist with or be complicated by pneumothorax.

Types of pneumothorax

Primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) occurs without underlying lung disease. The typical patient is a young (ages 18–40), tall, thin male. The mechanism is rupture of a subpleural bleb – a small air-filled sac that forms on the visceral pleura, most commonly at the lung apex. Blebs may form due to uneven mechanical stress at the apex during lung development. Smoking is the major modifiable risk factor: in a Swedish population study, smoking raised the relative risk of a first spontaneous pneumothorax about 9-fold in women and 22-fold in men, with a clear dose-response relationship (Bense et al., Chest 1987).

About a third of patients with PSP have a recurrence (32% overall in the Walker 2018 meta-analysis), most of them within the first year. Bilateral occurrence is uncommon but possible.

Management has shifted from size-based to symptom-based. Older teaching – and most NCLEX question banks – set the threshold at a 2–3 cm rim on CXR: smaller than that, observe; larger, drain. The 2023 BTS pleural disease guideline states that size is no longer an indication for invasive management. Size now mainly decides whether an intervention can be done safely (generally a rim of 2 cm or more on CXR), and a minimally symptomatic or asymptomatic PSP in an adult can be managed conservatively regardless of size. The evidence driving the change is the PSP trial (Brown et al., NEJM 2020), which randomized 316 patients aged 14–50 with moderate-to-large PSP to conservative versus interventional management. Conservative care met the non-inferiority margin for lung re-expansion within 8 weeks in the complete-case analysis (94.4% vs 98.5%), though not when missing data were counted as failures, and it carried a lower risk of serious adverse events or recurrence. Ambulatory management with a one-way-valve device is the other BTS-endorsed option where expertise and follow-up exist: in the RAMPP trial (Hallifax et al., Lancet 2020) it cut median hospital stay from 4 days to 0, at the cost of more adverse events. When a symptomatic PSP needs a procedure, needle aspiration and chest tube drainage have similar success rates, and aspiration shortens the hospital stay (by about 2.5 days in the BTS 2023 evidence review; see also Noppen 2002 and the Zehtabchi 2008 meta-analysis). Expect exam questions to still use the 2–3 cm rule; expect current practice to weigh symptoms and physiology first.

Secondary spontaneous pneumothorax

Secondary spontaneous pneumothorax (SSP) occurs in patients with known lung disease. The underlying disease weakens lung architecture, making bleb and bulla formation more likely. Common underlying conditions include:

• COPD / emphysema – the most common cause of SSP; bullae form as alveolar walls are destroyed
• Cystic fibrosis (CF) – recurrent infection and airway obstruction create structural weaknesses
• Marfan syndrome – connective tissue abnormality affects pleural integrity
• Tuberculosis (TB) – cavitary lesions and fibrosis predispose to air leak
• Malignancy – tumor necrosis can erode into the pleural space
• Pneumocystis jirovecii pneumonia (PJP) – particularly in immunocompromised patients

SSP patients tolerate collapse poorly because their underlying lung disease has already reduced respiratory reserve. A small SSP can produce severe symptoms requiring urgent intervention. In the BTS 2023 pathway, underlying lung disease is a high-risk feature: a symptomatic patient with SSP goes to chest drain insertion and admission rather than the outpatient conservative or ambulatory routes used for PSP, and even an asymptomatic SSP managed conservatively is reviewed as an inpatient. Recurrence after a first SSP runs 13–39%. UK practice has been to offer surgery after a second episode, but BTS 2023 suggests chemical pleurodesis can be considered even at the first episode for patients in whom another pneumothorax would be dangerous (for example, severe COPD that decompensated during the event). Surgery at first presentation is reserved for selected cases and weighed against surgical fitness.

Traumatic pneumothorax

Traumatic pneumothorax follows chest wall injury – either blunt trauma (motor vehicle crashes, falls) or penetrating injury (stab wounds, gunshot wounds, impalement). Rib fractures can lacerate the visceral pleura; penetrating wounds create a direct opening between the outside environment and the pleural space.

A key subtype is open pneumothorax (sucking chest wound), where a chest wall defect allows air to enter during inspiration through the wound rather than through the trachea. Standard field management is a 3-sided occlusive dressing, which acts as a flutter valve: seals on inspiration to prevent air entry, opens on expiration to allow air escape. A completely sealed dressing can convert an open pneumothorax to a tension pneumothorax.

Traumatic pneumothorax frequently coexists with hemothorax (blood in the pleural space) – together called hemopneumothorax.

Iatrogenic pneumothorax

Iatrogenic pneumothorax occurs as a complication of a medical procedure that inadvertently punctures the visceral pleura. Common causes include:

• Central venous catheter (CVC) insertion – particularly subclavian and internal jugular approaches
• Thoracentesis – a 2010 meta-analysis of 6,605 procedures found a 6.0% pneumothorax rate, about a third of which needed a chest tube; real-time ultrasound guidance cut the odds by roughly 70% (OR 0.3) (Gordon et al., Arch Intern Med 2010)
• Lung or pleural biopsy
• Mechanical ventilation – barotrauma from high pressures (volutrauma/barotrauma), especially in ARDS patients with stiff lungs

A CXR is commonly obtained after subclavian or internal jugular CVC insertion. After thoracentesis, the 2023 BTS pleural procedures statement says a routine CXR is not required when the procedure was straightforward and the patient has no symptoms; image the patient who develops breathlessness, chest pain, or cough, or whose procedure was difficult, and follow the provider’s order. BTS also notes that iatrogenic pneumothoraces tend to resolve more easily than spontaneous ones and often need no intervention, though a patient on positive-pressure ventilation is a different case.

Tension pneumothorax

Tension pneumothorax is the most dangerous type and a true emergency. A one-way valve mechanism develops – air enters the pleural space during inspiration but cannot escape during expiration. With each breath, more air accumulates, and intrapleural pressure rises progressively. This leads to:

1. Progressive collapse of the ipsilateral lung
2. Mediastinal shift away from the affected side
3. Compression of the contralateral lung (reducing total ventilation)
4. Compression of the superior and inferior vena cava, reducing venous return
5. Obstructive shock – cardiac output drops, blood pressure falls

Tension pneumothorax can arise from any type of pneumothorax, but is most commonly seen with penetrating trauma, positive-pressure mechanical ventilation, and improperly managed open chest wounds.

Pathophysiology

Simple pneumothorax

Under normal conditions, intrapleural pressure is negative (approximately −5 cmH₂O at rest, −8 cmH₂O during inspiration). This negative pressure keeps the visceral and parietal pleura apposed and maintains lung expansion. When air enters the pleural space – from any cause – this gradient is disrupted. The lung’s inherent elastic recoil causes it to collapse inward.

Physiologic consequences of lung collapse:

• Reduced tidal volume on the affected side – the collapsed lung cannot participate in gas exchange
• Ventilation-perfusion (V/Q) mismatch – blood continues to perfuse the collapsed lung (perfusion without ventilation = intrapulmonary shunt), causing hypoxemia
• Compensatory tachypnea – the patient breathes faster to maintain minute ventilation
• Hypoxemia and hypercapnia – worsen as the degree of collapse increases

Tension pneumothorax physiology

In tension pneumothorax, the ongoing accumulation of air under positive pressure produces mediastinal shift – the heart, trachea, and great vessels are pushed toward the unaffected side. Tracheal deviation is a late and unreliable sign: by the time the trachea shifts visibly, the patient is in extremis. Do not wait for tracheal deviation to act.

The hemodynamic collapse of tension pneumothorax follows from:

1. Increased intrathoracic pressure → compresses the vena cava → reduces preload → drops cardiac output
2. Mediastinal shift → kinks the great vessels → further reduces venous return
3. Hypoxemia → hypoxic vasoconstriction → further increases pulmonary vascular resistance

The result is obstructive shock – tachycardia, hypotension, cyanosis, and impending cardiac arrest if untreated.

Clinical presentation

Cardinal signs of tension pneumothorax

The classic teaching triad is: absent breath sounds (ipsilateral) + tracheal deviation (contralateral) + hypotension. However, this triad is a late-stage picture. In practice:

• Reduced or absent breath sounds unilaterally – a key bedside finding; assess with auscultation before imaging. In awake, spontaneously breathing patients, respiratory distress and tachycardia usually come first and hypotension late, while ventilated patients tend to deteriorate faster, with early hypotension and falling SpO₂ (Leigh-Smith and Harris, Emerg Med J 2005)
• Tracheal deviation – a late sign, present only when mediastinal shift is severe; do not wait for it
• Hypotension + tachycardia – indicate cardiovascular compromise; signal obstructive shock
• Jugular venous distension (JVD) – elevated venous pressure from impaired venous return; may be absent in hypovolemic patients
• Respiratory distress – tachypnea, accessory muscle use, cyanosis, decreasing oxygen saturation
• Agitation or altered mental status – from hypoxia and reduced cerebral perfusion

In mechanically ventilated patients: sudden rise in peak airway pressures, decreased compliance, declining SpO₂, and hemodynamic instability are the key warning signs – these patients cannot communicate symptoms.

Diagnosis and assessment

Clinical assessment

Nursing assessment starts with the ABCs. For suspected pneumothorax:

1. Auscultation – compare breath sounds bilaterally. Diminished or absent sounds on one side with pleuritic chest pain strongly suggest pneumothorax. In tension pneumothorax, breath sounds may be completely absent ipsilaterally.
2. Percussion – hyperresonance over the affected lung (air-filled pleural space rather than air-filled alveoli)
3. Inspection – unequal chest rise, accessory muscle use, tracheal position
4. Vital signs – tachycardia and falling SpO₂ are early warning signs; hypotension indicates progression toward tension

For tension pneumothorax: if clinical assessment strongly suggests tension PTX in a hemodynamically unstable patient, do NOT wait for imaging. Proceed to immediate needle decompression (see Emergency Management below).

Chest X-ray

CXR is the standard diagnostic imaging for stable patients:

• Absent lung markings over the affected area – the collapsed lung creates a hyperlucent (darker) zone without vascular markings
• Visible pleural line – the edge of the collapsed lung is visible as a white line separated from the chest wall
• Deep sulcus sign – on supine CXR (common in trauma), air collects anteriorly and inferiorly, producing a deep, lucent costophrenic angle; may be the only sign on an AP supine film
• Tracheal deviation – contralateral shift indicates significant tension
• Mediastinal shift – heart and mediastinum displaced away from affected side in tension

CXR can underestimate the size of a pneumothorax, particularly on supine films. A pneumothorax may appear small on CXR but be clinically significant.

CT scan

CT is more sensitive than CXR and can detect small pneumothoraces invisible on plain film. CT is indicated when:

• CXR is inconclusive and clinical suspicion is high
• Evaluating the extent of injury in chest trauma
• Planning surgical intervention
• The patient is stable and has underlying lung disease (accurately measuring size of SSP)

Do NOT delay treatment for CT if the patient is hemodynamically unstable.

ABG and pulse oximetry patterns

• SpO₂ – decreases as V/Q mismatch worsens; normal early in small pneumothorax
• PaO₂ – decreased; the degree of hypoxemia correlates roughly with the extent of collapse
• PaCO₂ – often normal or slightly decreased early (hyperventilation compensates); rises if respiratory fatigue sets in
• pH – respiratory alkalosis early; respiratory acidosis if fatigue or tension develops

Emergency management – tension pneumothorax

The critical decision: treat before imaging

Tension pneumothorax is a clinical diagnosis. In a hemodynamically unstable patient with clinical signs of tension pneumothorax, do NOT delay treatment to obtain a chest X-ray. Perform immediate needle decompression.

The rationale: tension pneumothorax can cause cardiac arrest within minutes. The time required to transport a patient to radiology, perform CXR, interpret results, and return to the bedside may be fatal. A false-positive needle decompression (treating a non-tension pneumothorax with needle decompression) causes a simple iatrogenic pneumothorax – a manageable complication. A missed tension pneumothorax causes death.

Decision algorithm

Patient with respiratory distress + chest symptoms
              ↓
Auscultate: Unilateral absent breath sounds?
              ↓ YES
Is the patient hemodynamically unstable?
(Hypotension, tachycardia, declining SpO₂)
         ↓ YES              ↓ NO
TENSION PNEUMOTHORAX     SIMPLE PNEUMOTHORAX
IMMEDIATE NEEDLE          → Obtain CXR
DECOMPRESSION             → Stable: symptom-based
Do NOT wait for CXR          management (BTS 2023)
         ↓
Follow with chest tube
(needle is temporary)

Needle decompression technique

ATLS changed the adult site in its 10th edition (2018): the 4th or 5th intercostal space, just anterior to the midaxillary line, replacing the traditional 2nd intercostal space at the midclavicular line (ICS 2-MCL). The reason is chest-wall thickness. At the 2nd ICS a standard catheter is often too short to reach the pleural space, so decompression fails. ATLS pairs the site with catheter length: about 5 cm for smaller adults and 8 cm for larger adults. In children, the 2nd ICS MCL remains the site. The European Trauma Course and UK prehospital guidance still teach ICS 2-MCL with an extra-long cannula, so you will meet both.

The 11th edition (2025) reorganized the primary survey as xABCDE, with exsanguinating hemorrhage control first. Its skills stations make finger thoracostomy and tube thoracostomy the mandatory breathing skill, with needle thoracostomy optional (ACS learning-lab guide, 2025). In the hospital, the definitive response to suspected tension is prompt pleural decompression and a chest tube. Needle decompression is a bridge when that will be delayed.

Failure rates for needle decompression are high. A 2025 meta-analysis (Ahmad et al., World J Emerg Surg) found the catheter failed to reach the pleural space in about a third of cases, and each extra centimeter of needle length cut the failure rate by about 7.8 percentage points. The authors proposed a 7 cm needle and advised against the left 5th ICS midaxillary site because of cardiac injury risk. These are the authors’ consensus suggestions and have not been adopted by ATLS.

Procedure (for the nurse assisting):

1. Provider identifies the intercostal space per protocol
2. Provider inserts a large-bore (typically 14 gauge) over-the-needle catheter of appropriate length over the superior border of the lower rib (the neurovascular bundle runs along the inferior border of each rib)
3. A rush of air and improving vital signs indicate decompression
4. The needle is removed and the catheter left in place
5. Secure the catheter, reassess, and prepare for chest tube insertion

Note: Needle decompression is a temporizing measure. Catheters kink, dislodge, and block, so re-tensioning can occur. It relieves tension but does not maintain pleural drainage. Definitive management requires chest tube insertion.

Chest tube for pneumothorax

Tube thoracostomy (chest tube) provides continuous pleural drainage:

• Size – the 2023 BTS pleural procedures statement says spontaneous and iatrogenic pneumothorax can be managed with small-bore drains (14 Fr or less, usually inserted by Seldinger technique), which hurt less. Larger drains are preferred for a substantial air leak: trauma, some secondary spontaneous pneumothoraces, and barotrauma in ventilated patients. For traumatic hemothorax, 28–32 Fr has replaced the old 36–40 Fr standard (BTS says sizes above 32 Fr are unlikely to be needed), and in stable patients a multicenter RCT found 14 Fr percutaneous catheters as effective as 28–32 Fr tubes (Kulvatunyou et al., J Trauma Acute Care Surg 2021)
• Location – the “safe triangle”: 4th or 5th intercostal space between the anterior and midaxillary lines; an anterior 2nd ICS MCL approach is used for some apical pneumothoraces
• Connected to an underwater seal drainage system (Pleur-evac or Atrium)

Chest tube management

Water seal drainage system components

A chest drainage system (Pleur-evac, Atrium) has three functional chambers:

1. Collection chamber – collects blood, fluid, or air draining from the pleural space; mark fluid level hourly in acute situations, or every shift in stable patients
2. Water seal chamber – acts as a one-way valve; filled with sterile water to the 2 cm mark; allows air to exit the pleural space but prevents backflow into the patient
3. Suction control chamber – regulates the amount of negative pressure applied when suction is ordered; wet suction systems are set by the water level (typically −20 cmH₂O); dry suction systems use a dial

Suction is not automatic. The BTS 2023 procedures statement advises against routine suction at the initial drainage of a pneumothorax because rapid re-expansion can cause re-expansion pulmonary edema (visible on imaging in up to a third of large pneumothoraces, though few patients have symptoms), and against routine suction in general given no proven benefit. If suction is used, the provider should prescribe the pressure. Keep the drain bottle upright and below the insertion site at all times, and keep enough water in the seal to cover the end of the tube.

Monitoring the water seal chamber

Clamping rules

Do NOT clamp a chest tube if an air leak is present. Clamping with an active air leak traps air in the pleural space and can cause or worsen a tension pneumothorax. The BTS 2023 procedures statement says clamping a bubbling drain should be avoided except under specialist pleural supervision in specific circumstances. Nursing texts describe brief momentary clamping to locate a leak (clamp at the dressing: if bubbling stops, the leak is at the insertion site or inside the chest; if it continues, the leak is in the tubing or unit), but do this only per your facility’s protocol or a provider order, never leave the clamp on, and watch the patient throughout. If the tubing disconnects, re-establish the seal immediately (reconnect, or place the tube end under sterile water) rather than leaving it clamped.

Drainage output monitoring

• Document drainage amount and color every hour in the acute setting, and at least daily (with swinging and bubbling) on a chest drain chart once stable
• A sudden rise in bloody output warrants immediate provider notification – it suggests active hemorrhage. Use the notification parameter in the provider’s order. For context, ATLS teaches that about 1,500 mL of blood on tube insertion, or continued output of about 200 mL/hour for 2–4 hours, should prompt consideration of surgical exploration
• Expected output is serosanguinous and gradually decreasing
• Do not allow the collection chamber to fill completely – change before it reaches capacity, using aseptic non-touch technique

Chest tube removal criteria

For a pneumothorax, the drain is removed when the lung has fully re-expanded on CXR and the air leak has stopped (no bubbling in the water seal chamber), and the patient is stable. Whether to do a “clamping trial” first, to unmask a small leak, varies by provider and has no prospective evidence behind it. Fluid-volume removal thresholds apply to hemothorax or effusion drains and are set by the provider.

During removal, instruct the patient to perform a Valsalva maneuver (bear down). The BTS 2023 procedures statement notes that whether the tube comes out at end-inspiration or end-expiration does not seem to change the risk of a residual pneumothorax as long as a Valsalva maneuver is done. The tube is withdrawn with a steady pull and the wound occluded straight away. A post-removal CXR should be considered to check for re-accumulation.

Nursing interventions

Positioning

• Semi-Fowler’s position (30–45 degrees) – the standard position for comfort and respiratory efficiency; uses gravity to expand the lower chest and reduces work of breathing
• Position of comfort, usually upright – unlike unilateral consolidation or effusion, a pneumothorax has no reliable lateral-positioning rule. Sitting upright is generally best tolerated. If a lateral position is used, lying on the unaffected side (“good lung down”) is the theoretically favorable one, since it directs the greater share of perfusion to the lung that is still ventilated. Evidence for routine lateral positioning in pneumothorax is weak, so do not override patient comfort or a specific provider order.
• Avoid positions that increase respiratory demand – restrict activity until the lung has re-expanded

Oxygen therapy

Give supplemental oxygen to correct hypoxemia. The BTS emergency oxygen guideline (O’Driscoll et al., Thorax 2017) sets a target SpO₂ of 94–98% for most patients with a pneumothorax, or 88–92% for those at risk of hypercapnic respiratory failure, such as many patients with COPD. It also notes that most patients with a pneumothorax are not hypoxemic.

High-flow oxygen to speed reabsorption is a separate, weaker indication. Breathing a high FiO₂ strips nitrogen from alveolar gas, steepening the gradient that pulls nitrogen out of the pleural space. Northfield’s small 1971 study found up to a fourfold increase in absorption rate, and a 2012 rabbit study confirmed faster resolution but found lung toxicity above 60% oxygen. On that basis, the 2017 BTS oxygen guideline, which is still current, recommends high-concentration oxygen (15 L/min via reservoir mask) for patients observed in hospital without drainage, unless they are at risk of hypercapnic respiratory failure (grade D, the lowest evidence grade). The 2023 BTS pleural guideline does not address oxygen, and its conservative and ambulatory pathways for primary spontaneous pneumothorax are largely outpatient, so this recommendation applies to a smaller group of patients than it once did. Follow the oxygen prescription and your facility’s protocol, and never give uncontrolled high-flow oxygen to a patient at risk of CO₂ retention.

Monitoring priorities

Frequencies and alert thresholds below are typical examples; use the provider’s orders and your facility’s early warning score where they differ.

Emergency preparedness

Keep at the bedside for any patient with a chest tube or high risk for tension pneumothorax:

• Decompression supplies per facility protocol (large-bore over-the-needle catheter long enough for the patient’s chest wall, typically 8 cm for an average or larger adult, plus a chest tube tray)
• Occlusive dressing materials (for open chest wound coverage)
• Extra chest tube drainage system
• Suction setup and functioning
• Emergency call system immediately accessible

Pain management

Pleuritic chest pain impairs deep breathing and coughing, increasing the risk of atelectasis and secretion retention. Adequate analgesia is a nursing priority. Approaches include:

• Scheduled non-opioid analgesics (acetaminophen, NSAIDs) as baseline
• Opioid analgesia for moderate-to-severe pain, particularly post-chest tube insertion
• Pillow splinting support when coughing
• Patient-controlled analgesia (PCA) in the post-procedure period for larger chest tubes

Patient education

Before discharge, patients need to understand the following:

Recurrence risk

• Primary spontaneous pneumothorax: a meta-analysis of 29 studies and 13,548 patients found a pooled overall recurrence rate of 32%, and a 1-year rate of 29%. Almost all of the lifetime risk therefore lands in the first twelve months, which is the number worth giving patients – the danger window is now, not spread evenly over five years.
• Secondary spontaneous: BTS 2023 gives a recurrence range of 13–39% after a first episode, and each recurrence in a patient with underlying lung disease carries greater risk. In cystic fibrosis, recurrence after chest tube drainage alone is about 50%
• BTS 2023 advises considering elective surgery (usually VATS with pleurodesis and/or bullectomy) after a second same-side or a first opposite-side pneumothorax, and earlier for people whose work makes recurrence dangerous (divers, pilots, military personnel) or who had a tension pneumothorax at the first episode

Smoking cessation

Smoking is a major modifiable risk factor. In the Walker meta-analysis, smoking cessation was associated with a roughly four-fold reduction in recurrence risk (OR 0.26) – a larger effect than most interventions nurses get to discuss. Frame cessation as the single most impactful thing the patient can do to prevent recurrence, and give them that number.

Activity and air travel restrictions

• Avoid strenuous exertion until the provider confirms resolution. Patients managed by observation or needle aspiration are usually brought back for a follow-up CXR at 2–4 weeks
• Air travel – BTS 2023 (and the 2022 BTS air travel statement) says not to fly while any pneumothorax remains on CXR. Once a CXR shows full resolution, patients can fly 7 days later; the wait is there to catch an early recurrence. Lower cabin pressure at altitude makes trapped air expand. Patients should be cleared by their provider.
• Scuba diving – should be discouraged permanently after a pneumothorax unless a very secure definitive prevention procedure, such as surgical pleurectomy, has been performed; pressure changes during ascent are dangerous
• Contact sports – avoid until medically cleared

When to return to the emergency department

Return immediately if:

• Sudden worsening chest pain or difficulty breathing
• Rapidly increasing shortness of breath
• Lips or fingernails turning blue
• Feeling faint or losing consciousness

NCLEX-style practice questions

Question 1. A nurse is caring for a patient admitted after a motor vehicle collision. On assessment: absent breath sounds on the left, tracheal deviation to the right, blood pressure 82/54 mmHg, heart rate 128 bpm, and SpO₂ 82% on high-flow oxygen. What is the nurse’s priority action?

A. Obtain a STAT portable chest X-ray B. Prepare the patient for chest tube insertion C. Notify the provider and prepare for immediate needle decompression D. Administer a 1-liter normal saline bolus

Answer: C. This patient has classic signs of tension pneumothorax: absent unilateral breath sounds, tracheal deviation away from the affected side, hypotension, and severe hypoxia. Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression – waiting for a chest X-ray (Option A) delays life-saving treatment. Chest tube insertion (Option B) is definitive management; when it cannot happen at once, needle (or finger) decompression comes first as the bridge. Fluid bolus (Option D) will not address the obstructive cause of hypotension.

Question 2. A nurse is monitoring a patient’s chest tube drainage system after insertion for a left pneumothorax. The water in the water seal chamber is fluctuating up with inspiration and down with expiration. How should the nurse interpret this finding?

A. The chest tube is kinked and requires repositioning B. There is an air leak in the drainage system C. The lung has fully re-expanded D. The chest tube is patent and functioning normally

Answer: D. Tidaling – the rise and fall of water in the water seal chamber with respiratory effort – is a normal finding indicating the tube is patent and communicating with the pleural space. Loss of tidaling (not the presence of it) would suggest the tube is obstructed or the lung has re-expanded.

Question 3. A patient with COPD suddenly develops severe dyspnea and right-sided pleuritic chest pain. Breath sounds are absent over the right upper and middle lung fields. The nurse suspects secondary spontaneous pneumothorax. Which intervention does the nurse anticipate?

A. Administer bronchodilators and supplemental oxygen; observe for 4 hours B. Prepare for chest tube insertion C. Position the patient prone and apply continuous cardiac monitoring D. Prepare the patient for thoracentesis using a lateral decubitus position

Answer: B. Secondary spontaneous pneumothorax in a patient with COPD is a serious event requiring active intervention. COPD patients have severely limited respiratory reserve, so a pneumothorax that might be managed conservatively in a healthy young adult (primary spontaneous) requires chest tube drainage in a patient with COPD. In the BTS 2023 pathway, underlying lung disease is a high-risk feature, so a symptomatic SSP goes to chest drain insertion and admission rather than the conservative or ambulatory routes used for primary spontaneous pneumothorax. Outpatient-style observation (Option A) fits a minimally symptomatic primary spontaneous pneumothorax. Prone positioning (Option C) is used in ARDS management. Thoracentesis (Option D) is for pleural effusion, not pneumothorax.

Question 4. A nurse notices continuous bubbling in the water seal chamber of a patient’s chest tube system approximately 8 hours after insertion. The bubbling was intermittent earlier in the shift. What should the nurse do first?

A. Clamp the chest tube and notify the provider immediately B. Assess all tubing connections for tightness and check the insertion site C. Document the finding and continue monitoring D. Increase the suction pressure to clear the air leak

Answer: B. Continuous bubbling indicates an air leak – either a persistent pneumothorax (patient-side) or a leak in the external system (connection or insertion site). The first step is to systematically check connections and the insertion site. Clamping (Option A) is dangerous if the air leak is from the patient – it traps air in the pleural space and can cause tension pneumothorax. Documenting only (Option C) is insufficient without investigation. Increasing suction (Option D) does not address the source of the leak.

Question 5. A nurse is preparing to care for a patient with a chest tube connected to wall suction at −20 cmH₂O. The nurse notes that there is no bubbling in the suction control chamber of a wet suction system. Which action is appropriate?

A. Increase the wall suction until continuous gentle bubbling is present in the suction control chamber B. Notify the provider that the suction is not functioning C. Document the finding – this is normal for a dry suction system D. Remove the chest tube, as the absence of bubbling indicates the lung has re-expanded

Answer: A. In a wet suction chest drainage system, the level of bubbling in the suction control chamber confirms that suction is being applied. Gentle continuous bubbling is the expected finding; absence of bubbling in a wet system indicates insufficient suction. The nurse should increase wall suction until gentle bubbling appears. Note: this question specifically describes a wet suction system – dry systems (such as the Atrium Oasis) use a dial and do not rely on bubbling in the suction chamber.

Question 6. A patient is being discharged after treatment for a primary spontaneous pneumothorax. The nurse is providing discharge education. Which statement by the patient indicates a need for further teaching?

A. “I should come back to the emergency department immediately if I have sudden chest pain or trouble breathing.” B. “I shouldn’t fly until an X-ray shows my lung has healed, and then I should wait another week.” C. “Since my lung is fully healed now, I can go back to scuba diving in a few months.” D. “Quitting smoking will reduce my chance of having another one of these.”

Answer: C. BTS guidance is that scuba diving should be discouraged permanently after a pneumothorax unless a very secure definitive procedure, such as surgical pleurectomy, has been performed. Gas trapped in the pleural space or in blebs expands as the diver ascends, and a recurrence underwater, far from help, can be fatal. Options A, B, and D are all correct patient education points: BTS advises waiting 7 days after the CXR shows full resolution before flying, and smoking cessation cut recurrence risk about four-fold in the Walker meta-analysis.

Key takeaways for NCLEX

• Tension pneumothorax is a clinical diagnosis – treat before imaging
• Tracheal deviation is a late sign; absent breath sounds + hypotension in context of chest trauma is enough to act
• Continuous bubbling = air leak (investigate; do not clamp)
• Tidaling = normal (tube patent); no tidaling = obstruction or re-expansion
• Never clamp a chest tube with an active air leak
• Symptomatic COPD + pneumothorax = secondary spontaneous = admit and expect a chest tube
• Minimally symptomatic primary spontaneous PTX can be managed conservatively at any size (BTS 2023)
• Flying: wait 7 days after the CXR shows full resolution
• Scuba diving: discouraged permanently after a pneumothorax unless surgical pleurectomy has been done

References

1. Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society Guideline for Pleural Disease. Thorax. 2023;78(Suppl 3):s1–s42. doi:10.1136/thorax-2022-219784
2. Asciak R, Bedawi EO, Bhatnagar R, et al. British Thoracic Society Clinical Statement on Pleural Procedures. Thorax. 2023;78(Suppl 3):s43–s68. doi:10.1136/thorax-2022-219371
3. Brown SGA, Ball EL, Perrin K, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. New England Journal of Medicine. 2020;382(5):405–415. doi:10.1056/NEJMoa1910775
4. Hallifax RJ, McKeown E, Sivakumar P, et al. Ambulatory Management of Primary Spontaneous Pneumothorax: An Open-Label, Randomised Controlled Trial. Lancet. 2020;396(10243):39–49. doi:10.1016/S0140-6736(20)31043-6
5. Walker SP, Bibby AC, Halford P, Stadon L, White P, Maskell NA. Recurrence Rates in Primary Spontaneous Pneumothorax: A Systematic Review and Meta-Analysis. European Respiratory Journal. 2018;52(3):1800864. doi:10.1183/13993003.00864-2018
6. Bense L, Eklund G, Wiman LG. Smoking and the Increased Risk of Contracting Spontaneous Pneumothorax. Chest. 1987;92(6):1009–1012. doi:10.1378/chest.92.6.1009
7. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Student Course Manual. 10th ed. Chicago, IL: American College of Surgeons; 2018. (Source of the 4th/5th ICS adult decompression site; see reference 8 for the 11th edition.)
8. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support, 11th Edition: Learning Labs (course guide, updated March 26, 2025). Chicago, IL: American College of Surgeons; 2025. Finger and tube thoracostomy listed as mandatory skills, needle thoracostomy optional.
9. Ahmad SJS, Degiannis JR, Head M, et al. Meta-Analysis of the Optimal Needle Length and Decompression Site for Tension Pneumothorax and Consensus Recommendations on Current ATLS and ETC Guidelines. World Journal of Emergency Surgery. 2025;20:39. doi:10.1186/s13017-025-00613-7
10. Sahota RJ, Sayad E. Tension Pneumothorax. StatPearls. Treasure Island (FL): StatPearls Publishing; 2025. PMID: 32644516
11. McKnight CL, Burns B. Pneumothorax. StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. PMID: 28722915
12. Leigh-Smith S, Harris T. Tension Pneumothorax – Time for a Re-Think? Emergency Medicine Journal. 2005;22(1):8–16. doi:10.1136/emj.2003.010421
13. Aylwin CJ, Brohi K, Davies GD, Walsh MS. Pre-hospital and In-hospital Thoracostomy: Indications and Complications. Annals of the Royal College of Surgeons of England. 2008;90(1):54–57. doi:10.1308/003588408X242286
14. Kulvatunyou N, Bauman ZM, Zein Edine SB, et al. The Small (14 Fr) Percutaneous Catheter (P-CAT) Versus Large (28–32 Fr) Open Chest Tube for Traumatic Hemothorax: A Multicenter Randomized Clinical Trial. Journal of Trauma and Acute Care Surgery. 2021;91(5):809–813. doi:10.1097/TA.0000000000003180
15. Gordon CE, Feller-Kopman D, Balk EM, Smetana GW. Pneumothorax Following Thoracentesis: A Systematic Review and Meta-Analysis. Archives of Internal Medicine. 2010;170(4):332–339. doi:10.1001/archinternmed.2009.548
16. O’Driscoll BR, Howard LS, Earis J, Mak V. BTS Guideline for Oxygen Use in Adults in Healthcare and Emergency Settings. Thorax. 2017;72(Suppl 1):ii1–ii90. doi:10.1136/thoraxjnl-2016-209729
17. Northfield TC. Oxygen Therapy for Spontaneous Pneumothorax. British Medical Journal. 1971;4(5779):86–88. doi:10.1136/bmj.4.5779.86
18. Zehtabchi S, Rios CL. Management of Emergency Department Patients with Primary Spontaneous Pneumothorax: Needle Aspiration or Tube Thoracostomy? Annals of Emergency Medicine. 2008;51(1):91–100. doi:10.1016/j.annemergmed.2007.06.009
19. Noppen M, Alexander P, Driesen P, et al. Manual Aspiration Versus Chest Tube Drainage in First Episodes of Primary Spontaneous Pneumothorax: A Multicenter, Prospective, Randomized Pilot Study. American Journal of Respiratory and Critical Care Medicine. 2002;165(9):1240–1244. doi:10.1164/rccm.200111-078OC
20. Chan SS, Rainer TH. Primary Spontaneous Pneumothorax: 1-Year Recurrence Rate After Simple Aspiration. European Journal of Emergency Medicine. 2006;13(2):88–91. doi:10.1097/01.mej.0000192047.97105.59
21. Sahn SA, Heffner JE. Spontaneous Pneumothorax. New England Journal of Medicine. 2000;342(12):868–874. doi:10.1056/NEJM200003233421207
22. Merkle A, Lobo CM, Cindass R. Care of a Chest Tube. StatPearls. Treasure Island (FL): StatPearls Publishing; 2025. PMID: 32310548
23. MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of Spontaneous Pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(Suppl 2):ii18–ii31. doi:10.1136/thx.2010.136986 (superseded by reference 1; this edition used size to decide on intervention, which BTS 2023 dropped)
24. Baumann MH, Strange C, Heffner JE, et al. Management of Spontaneous Pneumothorax: An American College of Chest Physicians Delphi Consensus Statement. Chest. 2001;119(2):590–602. doi:10.1378/chest.119.2.590 (historical consensus statement; retained for context, not current practice)