A 70-year-old man with chronic obstructive pulmonary disease (FEV1 45% predicted, 45 pack-years, current smoker) presents to the emergency department with 3 hours of sudden right-sided pleuritic chest pain and worsening shortness of breath. He uses tiotropium/olodaterol daily and salbutamol as needed, and has no known drug allergies. He is speaking in short sentences. On examination, breath sounds are markedly decreased and percussion is hyperresonant over the right hemithorax; the trachea is midline and neck veins are not distended. A chest x-ray shows absent lung markings beyond a visible pleural line, with 4 cm between the pleural line and the right lung apex; the mediastinum is not shifted.
| Heart rate | 108/min |
| Respiratory rate | 26/min |
| Temperature | 36.8 °C |
| O2 saturation | 88%, room air (usual 92%) |
| Blood pressure | 130/80 mm Hg |
Question 1 of 30
Which of the following are the most appropriate initial management steps?
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