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

Tension Pneumothorax Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

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. It tends to occur in clinical situations such as ventilation, resuscitation, trauma, or in patients with lung disease. The aim of tension pneumothorax management is to relieve the pressure from thorax.

Causes

Life Threatening Causes

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

Common Causes

Tension pneumothorax can be a complication of primary, or secondary pneumothorax. The most common causes of tension pneumothorax are:

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

Diagnosis

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

Characterize the symptoms: Tension pneumothorax requires immediate intervention,and diagnosis should be made based on the history and physical examination findings ❑ Breathlessness ❑ Chest pain ❑ Cyanosis ❑ Sweating ❑ Anxiety ❑ Fatigue ❑ Air way pressure alarm: if on mechanical ventilation

Consider risk factors: ❑ Cigarette smoking ❑ Risk of pneumothorax is higher in smokers (12%) than non-smokers (0.1%). ❑ Recent invasive procedures ❑ Thoracentesis ❑ Central venous catheter ❑ Bronchoscopy ❑ Cystic fibrosis ❑ 16% to 20% of patients with cystic fibrosis >18 years of age will experience pneumothorax.

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 vocal fremitus ❑ Displacement of the apex beat Percussion ❑ Hyperresonance Auscultation ❑ Diminished breath sounds on the affected side

Consider alternative diagnoses: ❑ Acute myocardial infarction ❑ Nausea, vomiting, and diaphoresis ❑ Triggered by exercise ❑ Substernal discomfort ❑ Pain radiate to the neck and the arms ❑ Asthma ❑ Expiratory wheeze ❑ Pericardial tamponade ❑ Sharp,stabbing chest pain ❑ Syncope/presyncope ❑ Emphysema ❑ Past history of emphysema ❑ Musculoskeletal pain ❑ Tenderness on palpation ❑ Pain increase with respiration ❑ Rib fracture ❑ History of trauma ❑ Severe tenderness ❑ Pulmonary embolism ❑ Risk factors for thromboembolism ❑ Recent fracture ❑ Deep venous thrombosis

Imaging studies In clinically diagnosed hemodynamically unstable patients, proceed immediately to needle decompression ❑ Chest X-ray ❑ Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal 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

Treatment

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

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, midclavicular line ❑ 4th or 5th intercostal space mid or anterior axillary line, if Initial decompression is failed because of thick chest wall ❑ Listen for gush of air ❑ Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system ❑ Check chest tubes, as they can become plugged or malpositioned and stop functioning ❑ Don`t repeat needle aspiration unless there were technical difficulties ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|250|How to do a needle decompression}} Video adapted from Youtube.com Antibiotic therapy ❑ First-generation cephalosporin ❑ An initial parenteral dose to decrease the risk of empyema and pneumonia

Admit the patient ❑ Refer the patient to respiratory specialist within 24h of admission

Insert chest drain ❑ Timing of procedures: ❑ Complications are higher when performed after midnight ❑ If emergent, do it immediately regardless the time ❑ Image guidance ❑ A recent chest X-ray before the procedure ❑ Standard erect Postro-anterior chest x-ray ❑ Lateral x-rays provide additional information ❑ Ensure aseptic technique ❑ Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful ❑ 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 Avoid complications: ❑ Pain ❑ Analgesia ❑ Local anesthesia ❑ Intrapleural infection ❑ Aseptic technique ❑ Wound infection ❑ Antibiotics prophylaxis ❑ Drain dislodgement and blockage ❑ Frequent checking ❑ Visceral injury ❑ Proper insertion technique

Discharge and follow up ❑ All patients should be followed up by respiratory physicians ❑ Advise to return to hospital if increasing breathlessness develops ❑ Advice to avoid air travel ❑ Advice to avoid Diving

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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