Tension pneumothorax resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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

Overview

Tension pneumothorax is a medical emergency caused by accumulation of air in the pleural cavity. Air enter the intrapleural space through the lung parenchyma, or through a traumatic communication from the chest wall.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying causes.

Common Causes

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

Management

Shown below is an algorithm depicting the management of tension pneumothorax.

Characterize the symptoms: ❑ Breathlessness ❑ Chest pain ❑ Cyanosis ❑ Sweating ❑ Anxiety ❑ Fatigue ❑ Air way pressure alarm: if on mechanical ventilation

Examine the patient: Vital signs ❑ Respiratory rate: ❑ Severe tachypnea ❑ Heart rate: ❑ Tachycardia ❑ Blood pressure ❑ Hypotension Focused chest examination Inspection ❑ Reduced lung expansion on the affected side ❑ Enlarged involved hemithorax ❑ Jugular venous distension Palpation ❑ Trachea shifted to the opposite side ❑ Decreased tactile vocal fremitus Percussion ❑ Hyperresonance Auscultation ❑ Diminished breath sounds on the affected side

First aid: ❑ Airway, breathing, and circulation (ABC) ❑ Sucking chest wounds immediately coveraged with an occlusive or pressure bandage ❑ 100% oxygen administration

Manage the patient with a multidisciplinary team: ❑ Consult a thoracic surgeon ❑ Consult a cardiologist

Consider other diseases with similar presentations: ❑ Acute myocardial infarction ❑ Pericardial tamponade ❑ Emphysema

Categorize the Patient

Hemodynamically Stable

Hemodynamically Unstable

Confirm diagnosis Imaging studies ❑ Chest X-ray Left-sided tension pneumothorax ❑ Erect position in inspiration ❑ Air in the pleural cavity ❑ Contralateral deviation of mediastinum ❑ Increased thoracic volume ❑ Ipsilateral flattening of heart border ❑ Mid diaphragmatic depression ❑ Chest CT scanning ❑ For uncertain or complex cases Left-sided pneumothorax (on the right side of the image). A chest tube is in place-side of chest, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white). The heart can be seen in the centre. ❑ Ultrasonography ❑ Digital imaging

Emergency needle decompression ❑ Aseptic preparation ❑ Use two alcohol-based skin disinfectant ❑ Use 14-16 G intravenous cannula ❑ Site ❑ Tension pneumothorax may affect breath sounds on both sides, be sure you are on the diseased side ❑ 2nd intercostal space, mid-clavicular line ❑ 4th or 5th intercostal space if Initial decompression is failed because of thick chest wall Antibiotic therapy ❑ First-generation cephalosporin ❑ An initial parenteral dose to decrease the risk of empyema and pneumonia

Aspirate using 14-16 G cannula

Admit the patient

Insert chest drain ❑ Site: the triangle of safety bordered by ❑ 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 ❑ Requirments ❑ Written consent ❑ Clean area for the procedure ❑ Competent operator and nursing staff ❑ Equipment required ❑ 1% lignocaine ❑ Alcohol based skin cleanser ❑ 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

❑ Pleural space size < 2cm ❑ Breathing improved

❑ Pleural space size > 2cm ❑ Breathlessness

Follow Up

Chest drain

Do`s

• Tension pneumothorax diagnosis should be made based on the history and physical examination findings.
• Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.
• Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system
• Suspect tension pneumothorax with blunt and penetrating trauma to the chest
• Differentiate tension pneumothorax from pericardial tamponade, and myocardial infarction.
• Suspect tension pneumothorax in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.
• Check chest tubes, as they can become plugged or malpositioned and stop functioning.
• Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.
• Refer the patient to respiratory specialist within 24h of admission.

Dont`s

• Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.
• Don`t use large bore chest drains.
• Don`t repeat needle aspiration unless there were technical difficulties.

References

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