Tension pneumothorax resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamed Moubarak, M.D. [2]; Twinkle Singh, M.B.B.S. [3]

Synonyms and keywords: Collapsed lung; air around the lung; air outside the lung

Tension Pneumothorax Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
FIRE
Complete Diagnostic Approach
Treatment
Do's
Don'ts

Overview

Tension pneumothorax is a medical emergency resulting from the accumulation of air in the pleural cavity. Air enters the intrapleural space as a result of disruption in the parietal pleura, visceral pleura or tracheobronchial tree. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the pleural cavity rises above the atmospheric pressure and results in respiratory and cardiovascular failure. Tension pneumothorax can occur as a result of trauma, ventilation, resuscitation and preexisting lung disease.[1] Commonly, the patient presents with severe dyspnea and chest pain. It should be managed immediately with emergency needle decompression.

Causes

Life Threatening Causes

Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Diagnosis

First Initial Rapid Evaluation of Suspected Tension Pneumothorax

Shown below is an algorithm for the First Initial Rapid Evaluation (FIRE) of suspected tension pneumothorax.[1]

 
 
 
 
 
 
 
 
 
Identify cardinal signs and symptoms that increase the pretest probability of tension pneumothorax
❑ Sever dyspnea
Chest pain
Cyanosis
❑ Decreased level of consciousness (in late stages)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify any alarming signs or symptoms
Jugular venous distension
Tachycardia
Hypotension
❑ Severe dyspnea
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable patient
 
 
 
Stable patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess airway, breathing, and circulation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with immediate needle decompression in the 2nd intercostal space, midclavicular line of affected hemithorax
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Insert chest drain immediately after needle decompression
 
 
 
 
 
 
 
 
 
 
 


Complete Diagnostic Approach in Patients with Tension Pneumothorax

Shown below is an algorithm depicting the diagnostic approach of tension pneumothorax based on the British Thoracic Society Pleural Disease Guideline 2010.[1]
Tension pneumothorax requires immediate intervention. It should be diagnosed based on the history and physical examination findings.

Abberviations: DVT: Deep venous thrombosis; CT: Computed tomography

 
 
 
Characterize the symptoms:

Dyspnea
Chest pain
Cyanosis
Sweating
Anxiety
Fatigue
❑ Decreased level of consciousness (in late stages)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify the precipitating factors:

❑ Recent invasive procedures

Thoracentesis
Central venous catheter insertion
Bronchoscopy
Pleural biopsy

Mechanical ventilation
Cardiopulmonary resuscitation
❑ Presence of chest drains
Hyperbaric oxygen treatment

Chest wall trauma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Appearance of the patient
❑ Severe distressed and labored respiration

Vital signs

Pulse

❑ Rate
Tachycardia
❑ Rhythm
❑ Regular
❑ Strength
❑ Weak

Blood pressure

Hypotension

Respiratory rate

Tachypnea

Skin

Cyanosis

Neck

Jugular venous distension (absent in severe hypotension)

Respiratory examination:

Inspection
❑ Enlargement of the invovled side
Intercostal space widening on the affected side
Palpation
❑ Reduced lung expansion on the affected side
Trachea shifted to the contralateral side
❑ Decreased vocal fremitus over the affected side
❑ Displacement of the apex beat
Percussion
Hyperresonance over the affected side
Auscultation
❑ Diminished breath sounds on the affected side

Additional findings in ventilated patients:

❑ Decreased oxygen saturation
❑ Increase in inflation pressure
❑ Increase in peak airway pressure

❑ Airway pressure alarm in mechanically ventilated patients
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:

Acute myocardial infarction

❑ Substernal chest discomfort or chest tightness

Pericardial tamponade

Chest pain
Cough
Pleuritic pain
Cyanosis
Dyspnea
Fatigue
Orthopnea
Near syncope
Loss of consciousness
Cool extremities
Peripheral cyanosis
Peripheral edema

Pulmonary embolism

❑ Presence of risk factors for pulmonary embolism
❑ Physical exam suggestive of DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemodynamically unstable
 
Hemodynamically stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with immediate needle decompression
 

Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension
Imaging studies:
❑ Order chest X-ray

❑ Air in the pleural cavity
❑ Contralateral deviation of mediastinum
❑ Increased thoracic volume
❑ Ipsilateral flattening of heart border
❑ Mid diaphragmatic depression


Picture courtesy of Wikidoc.org The image depicts tension pneumothorax in the left lung.
❑ Perform serial chest X-ray every 6 hours to rule out pneumothorax in cases of trauma.[2]


❑ Order chest CT scan for uncertain or complex cases

Picture courtesy of Wikidoc.org The image depicts left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).

❑ Order ultrasonography in supine trauma patients
 

Treatment

Shown below is an algorithm depicting the treatment approach to tension pneumothorax based on the British Thoracic Society Pleural Disease Guideline 2010.[1]

 
 
 
Initial supportive measures

❑ Assess airway, breathing, and circulation (ABC)
❑ Immediately cover penetrating chest wounds with an occlusive or pressure bandage in trauma patients
❑ Administer 100% oxygen [2]

❑ Seek expert consultation (thoracic surgeon)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform emergency needle decompression

❑ Ensure aseptic preparation

❑ Use alcohol-based skin disinfectants (two applications)

❑ Use 14-16 gauge intravenous cannula
❑ Determine the site of insertion of the needle

❑ 2nd intercostal space, midclavicular line of affected hemithorax, OR
❑ 4th or 5th intercostal space on mid or anterior axillary line, if the initial decompression failed because of a thick chest wall[1]

Don't repeat needle aspiration unless there were technical difficulties.
Don't remove the cannula, until the chest drain is inserted and is functioning properly.
❑ Confirm the diagnosis by observing instantaneous escape of air
Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}} Video adapted from Youtube.com

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Insert chest drain immediately after needle decompression

❑ Obtain the informed consent
❑ Make sure that the following equipments are available:

❑ 1% lignocaine
Iodine or chlorhexidine solution in alcohol
❑ Sterile drapes, gown, gloves
❑ Needles, syringes, gauze swabs
❑ Scalpel, suture (0 or 1-0 silk)
Chest tube kit
❑ Closed system drain (including water) and tubing
❑ Dressing
❑ Clamp

❑ Use a recent chest X-ray to guide the drain insertion
❑ Administer adequate analgesics
❑ Administer initial parenteral dose of first-generation cephalosporins only in patients with chest wall trauma (to decrease the risk of empyema and pneumonia)
❑ Ensure asepsis
❑ Determine the insertion site

❑ Superiorly: the base of the axilla
❑ Anteriorly: lateral edge of pectoralis major
❑ Laterally: lateral edge of latissimus dorsi
❑ Inferiorly: the line of the fifth intercostal space

❑ Insert the chest drain
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (this is a sign that the chest drain is functioning properly)
❑ Check chest tubes frequently, as they can become plugged or malpositioned

❑ Remove the chest tube after re-expansion of the affected lung is confirmed by a chest X-ray
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow up

❑ All patients should be followed up by a chest physician
❑ Advise to return to the hospital if increasing breathlessness develops
❑ Advise to avoid air travel
❑ Advise to avoid diving

 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

  • Suspect tension pneumothorax with blunt and penetrating trauma to the chest.
  • Suspect tension pneumothorax in patients on mechanical ventilation who develop a rapid onset of hemodynamic instability or cardiac arrest and require an increase in the peak inspiratory pressure.
  • Order serial chest radiographs every 6 hrs on the first day following chest trauma to rule out pneumothorax.[2]
  • Administer adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.
  • Refer the patient to a respiratory specialist within 24 hours of admission.
  • Order a chest X-ray before chest tube removal to confirm reexpansion of the affected lung.

Don'ts

  • Don't remove the needle from the 2nd intercostal space unless the patient is stable.
  • Don't use large bore chest drains.[1]
  • Don't leave the chest drain more than 7 days, as it will increase the risk of infection.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group (2010). "Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010". Thorax. 65 Suppl 2: ii18–31. doi:10.1136/thx.2010.136986. PMID 20696690.
  2. 2.0 2.1 2.2 Sharma A, Jindal P (2008). "Principles of diagnosis and management of traumatic pneumothorax". J Emerg Trauma Shock. 1 (1): 34–41. doi:10.4103/0974-2700.41789. PMC 2700561. PMID 19561940.


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