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Introduction International guidelines for the management Primary spontaneous pneumothorax (PSP) vary on the definition of size, and treatment of PSP. The American consensus based ACCP guidelines recommend removal of air via an intercostal drain (ICD) in large PSP, and the BTS guidance suggest needle aspiration (NA) first, with quoted success rates of 30%-80%. In 2005/6 there were 5954 finished consultant episodes for PSP in England. Methods We performed a retrospective audit of PSP presenting to the Emergency Department (ED) over a 24-month period. Electronic patient records (ED and inpatient) were keyword searched for "pneumothorax" and x-rays were interrogated. We used HRG code DZ26B ("Pneumothorax without complications"), with a tariff of £1840.83 per episode to calculate cost implications. Measure of agreement of PSP size was assessed with Cohen's κ. Results 43 confirmed pneumothorax cases were identified, 37 PSP. Of those with PSP: mean (SD) age was 28 (6.9) years, 31 (84%) were male, 23 (62%) were right sided. See Abstract P35 table 1 for assessment of PSP size. 21 (56.8%) had NA, successfully in 8 (38%). 17 (46%) patients had an ICD placed; 12 (70.6%) with <14F drains. Median length of stay following ICD was 5 (IQR 2 12) days. 28 e (75.6%) had appropriate adherence to BTS guidelines (4 (10.8%) were not aspirated, 5 (13.5%) had a large, rather than small, ICD). 14 (37.8%) patients were sent for thoracoscopic surgery (on site), 4 (9.2%) PSP not resolving, 10 due to ipsi-, or contralateral, reoccurrence of PSP. If Nationally 10% of patients do not have NA as first line treatment, then (assuming a 40% success rate), this may be costing the NHS in England up to £438 412 a year in preventable admissions. Adherence to ACCP guidance would cost the NHS in England an extra £3.9 million in additional ICDs and hospital admissions. Conclusions ACCP and BTS guidance on PSP size have only poor-fair agreement. Local practice to increase NA rates and use of small drains should be adopted. Adherence to appropriate National guidelines has large healthcare economic implications. [ABSTRACT FROM AUTHOR]