Tension pneumothorax resident survival guide

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
Treatment
Do's
Don'ts

Overview

Tension pneumothorax is a medical emergency that results from the accumulation of air in the pleural cavity. Air enters the intrapleural space as a result of the disruption in the parietal pleura, visceral pleura or tracheobronchial tree. This disruption leads to 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 or preexisting lung disease. Commonly, the patient presents with acute severe dyspnea and chest pain. Tension pneumothorax 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

• Asthma
• Central venous catheter
• Cardiopulmonary resuscitation
• Chronic obstructive pulmonary disease
• Emphysema
• Mechanical ventilation
• Trauma

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.

Identify cardinal signs and symptoms that increase the pretest probability of tension pneumothorax: ❑ Severe dyspnea ❑ Chest pain ❑ Cyanosis ❑ Altered mental status classification (in late stages)

Identify 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

Continue with the diagnostic approach

❑ Insert chest drain immediately after needle decompression

Complete Diagnostic Approach to Tension Pneumothorax

Shown below is an algorithm depicting the diagnostic approach of tension pneumothorax based on the British Thoracic Society Pleural Disease Guideline 2010.
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. ❑ 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.

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 ❑ 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 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.
• 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.
• Don't leave the chest drain more than 7 days, as it will increase the risk of infection.

References

Template:WikiDoc Sources