1. Increase FIO2 if hypoxaemic.

2. If life-threatening with circulatory collapse, needle aspirate pleura on affected side, followed by formal chest drain insertion.

3. Repeated needle aspiration may be sufficient in spontaneously breathing patients without respiratory failure; however, this is not recommended if the patient is ventilated.

4. Chest drain insertion. This may be done under ultrasound or CT guidance, especially if localised due to surrounding lung fibrosis.

A small pneumothorax (<10% hemithorax) may be left undrained but prompt action should be instituted if cardiorespiratory deterioration occurs. Patients should not be transferred between hospitals, particularly by plane, with an undrained pneumothorax. Drains may be removed if not swinging/bubbling for several days.

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