Tension pneumothorax: Difference between revisions

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==Background==
==Background==
*Pneumothorax with ongoing air leak creating a one-way valve mechanism → progressive accumulation of air under pressure in the pleural space
*Progressive accumulation of air in the pleural space with a one-way valve mechanism
*Causes mediastinal shift, compression of contralateral lung, and impaired venous return → [[obstructive shock]] → cardiac arrest
*Air enters on inspiration but cannot escape on expiration
*'''Death occurs from impaired venous return and hypoxia''' — this is a clinical diagnosis treated immediately without waiting for imaging
*Causes mediastinal shift, decreased venous return, and cardiovascular collapse
*Causes: penetrating or blunt [[thoracic trauma]], mechanical ventilation (barotrauma), central line placement, [[pneumothorax (main)|spontaneous pneumothorax]] with valve mechanism
*A clinical diagnosis — treatment should NOT be delayed for imaging<ref name="roberts">Roberts DJ, et al. Clinical presentation of patients with tension pneumothorax. ''Ann Surg''. 2015;261(6):1068-1078. PMID 25563886.</ref>
*Most common in [[Trauma|trauma]], positive pressure ventilation, and after procedures (central line, thoracentesis)
 
==Etiology==
*[[Traumatic pneumothorax]] (penetrating or blunt)
*Positive pressure ventilation (mechanical ventilation, NIPPV, BVM)
*Iatrogenic (central venous catheterization, [[Thoracentesis|thoracentesis]], nerve blocks)
*Spontaneous (especially in tall, thin males; underlying [[COPD]], [[Asthma|asthma]])


==Clinical Features==
==Clinical Features==
*Unilateral diminished or absent breath sounds
*Hypotension and tachycardia (most sensitive findings)
*[[Hypotension]] or hemodynamic instability (obstructive shock — impaired RV filling)
*Respiratory distress, [[tachypnea]], [[Hypoxia|hypoxia]]
*Distended neck veins (may not occur if patient is hypovolemic)
*Decreased or absent breath sounds on affected side
*Contralateral tracheal deviation ('''late finding''' — do not wait for this)
*Tracheal deviation away from affected side (late finding, unreliable in acute setting)
*[[Tachycardia]], [[tachypnea]], [[hypoxia]]
*Jugular venous distension (may be absent with concurrent hypovolemia)
*[[Cardiac arrest]] ([[PEA]] or asystole) — always consider tension pneumothorax in traumatic arrest
*Hyperresonance to percussion on affected side
*Subcutaneous emphysema
*[[PEA]] arrest or sudden cardiovascular collapse
*Consider in intubated patients with '''acute deterioration''' ([[DOPE]] mnemonic)


==Differential Diagnosis==
==Differential Diagnosis==
{{Pneumothorax types}}
*[[Simple pneumothorax]]
{{Thoracic trauma DDX}}
*[[Hemothorax]]
*[[Cardiac tamponade]]
*[[Massive pulmonary embolism]]
*Right mainstem intubation
*Auto-PEEP / air trapping
*[[Myocardial infarction]]


==Evaluation==
==Evaluation==
[[File:PMC2892654 CRM2010-213818.004.png|thumb|Left sided tension pneumothorax with mediastinal shift]]
*'''Clinical diagnosis''' — do NOT delay treatment for CXR or CT
'''This is a clinical diagnosis — do NOT delay treatment for imaging'''
*Point-of-care [[Ultrasound|ultrasound (POCUS)]]: absent lung sliding on affected side (high sensitivity)<ref name="licht">Lichtenstein DA, et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. ''Chest''. 2008;134(1):117-125. PMID 18403664.</ref>
*[[CXR]] (if time permits and patient is stable): mediastinal shift, unilateral hyperlucency, deep sulcus sign
*CXR (if time permits): hyperlucency, absent lung markings, mediastinal shift, deep sulcus sign (supine)
*[[Ultrasound: Lungs|Lung ultrasound]]: absent lung sliding on affected side (rapid bedside confirmation)
*CT chest: definitive but rarely indicated acutely
{{Lung ultrasound pneumothorax}}


==Management==
==Management==
===Immediate Decompression===
===Immediate Decompression===
*'''Needle thoracostomy''' (decompression) — temporizing measure:
*Needle decompression (temporizing measure):
**14-gauge angiocatheter, 2nd intercostal space midclavicular line (traditional)
**14-16 gauge angiocatheter
**Evidence suggests 4th-5th intercostal space at anterior axillary line has lower failure rate (less chest wall thickness)
**Site: 5th intercostal space, anterior axillary line (preferred) or 2nd ICS midclavicular line<ref name="inaba">Inaba K, et al. Radiographic evaluation of alternative sites for needle decompression of tension pneumothorax. ''Arch Surg''. 2012;147(9):813-818. PMID 22987168.</ref>
**Failure rate with standard needle is up to 50% in obese or muscular patients
**Insert over the top of the rib (avoid neurovascular bundle on inferior rib margin)
*'''Finger thoracostomy''' — more reliable than needle decompression:
**Rush of air confirms diagnosis
**4th-5th intercostal space, anterior axillary line
**May fail due to chest wall thickness — consider longer catheter (8 cm) or finger thoracostomy
**Make incision through skin and intercostal muscles, bluntly enter pleural space with finger
**Preferred in cardiac arrest or when needle decompression fails
*'''Always followed by [[chest tube]] placement''' (needle/finger alone is not definitive)


===Chest Tube===
===Definitive Treatment===
*Adult: 28-36 Fr
*[[Chest tube|Tube thoracostomy]] (28-36 Fr)
*Pediatric: Estimated as 4 × ETT size (ETT = 4 + age/4)
**Required after needle decompression
{{Chest tube size table}}
**5th ICS, anterior to mid-axillary line
**Connect to underwater seal / Pleurovac
*In cardiac arrest: bilateral finger thoracostomies
 
===Cardiac Arrest===
*Tension pneumothorax is a reversible cause of [[PEA]] arrest (the ''T'' in H's and T's)
*Bilateral needle or finger thoracostomy during CPR
*If ROSC not achieved after decompression, consider other causes


==Disposition==
==Disposition==
*Admit all patients after chest tube placement
*Admit all patients with tension pneumothorax
*ICU if hemodynamically unstable or on mechanical ventilation
*ICU admission if hemodynamic instability, mechanical ventilation, or ongoing air leak
{{Flying instructions after pneumothorax}}
*Trauma surgery or thoracic surgery consultation
 
==Complications==
*[[Reexpansion pulmonary edema]] (rare but serious)
*Tube malposition or dislodgement


==See Also==
==See Also==
*[[Pneumothorax (main)]]
*[[Spontaneous pneumothorax]]
*[[Needle thoracostomy]]
*[[Finger thoracostomy]]
*[[Chest tube]]
*[[Chest tube]]
*[[Adult pulseless arrest#Asystole and PEA (Non-Shockable)|Traumatic arrest]]
*[[Hemothorax]]
*[[Thoracic trauma]]
*[[Deterioration After Intubation (DOPE)]]


==References==
==References==

Latest revision as of 09:23, 22 March 2026

Background

  • Progressive accumulation of air in the pleural space with a one-way valve mechanism
  • Air enters on inspiration but cannot escape on expiration
  • Causes mediastinal shift, decreased venous return, and cardiovascular collapse
  • A clinical diagnosis — treatment should NOT be delayed for imaging[1]
  • Most common in trauma, positive pressure ventilation, and after procedures (central line, thoracentesis)

Etiology

  • Traumatic pneumothorax (penetrating or blunt)
  • Positive pressure ventilation (mechanical ventilation, NIPPV, BVM)
  • Iatrogenic (central venous catheterization, thoracentesis, nerve blocks)
  • Spontaneous (especially in tall, thin males; underlying COPD, asthma)

Clinical Features

  • Hypotension and tachycardia (most sensitive findings)
  • Respiratory distress, tachypnea, hypoxia
  • Decreased or absent breath sounds on affected side
  • Tracheal deviation away from affected side (late finding, unreliable in acute setting)
  • Jugular venous distension (may be absent with concurrent hypovolemia)
  • Hyperresonance to percussion on affected side
  • Subcutaneous emphysema
  • PEA arrest or sudden cardiovascular collapse
  • Consider in intubated patients with acute deterioration (DOPE mnemonic)

Differential Diagnosis

Evaluation

  • Clinical diagnosis — do NOT delay treatment for CXR or CT
  • Point-of-care ultrasound (POCUS): absent lung sliding on affected side (high sensitivity)[2]
  • CXR (if time permits): hyperlucency, absent lung markings, mediastinal shift, deep sulcus sign (supine)
  • CT chest: definitive but rarely indicated acutely

Management

Immediate Decompression

  • Needle decompression (temporizing measure):
    • 14-16 gauge angiocatheter
    • Site: 5th intercostal space, anterior axillary line (preferred) or 2nd ICS midclavicular line[3]
    • Insert over the top of the rib (avoid neurovascular bundle on inferior rib margin)
    • Rush of air confirms diagnosis
    • May fail due to chest wall thickness — consider longer catheter (8 cm) or finger thoracostomy

Definitive Treatment

  • Tube thoracostomy (28-36 Fr)
    • Required after needle decompression
    • 5th ICS, anterior to mid-axillary line
    • Connect to underwater seal / Pleurovac
  • In cardiac arrest: bilateral finger thoracostomies

Cardiac Arrest

  • Tension pneumothorax is a reversible cause of PEA arrest (the T in H's and T's)
  • Bilateral needle or finger thoracostomy during CPR
  • If ROSC not achieved after decompression, consider other causes

Disposition

  • Admit all patients with tension pneumothorax
  • ICU admission if hemodynamic instability, mechanical ventilation, or ongoing air leak
  • Trauma surgery or thoracic surgery consultation

See Also

References

  1. ↑ Roberts DJ, et al. Clinical presentation of patients with tension pneumothorax. Ann Surg. 2015;261(6):1068-1078. PMID 25563886.
  2. ↑ Lichtenstein DA, et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125. PMID 18403664.
  3. ↑ Inaba K, et al. Radiographic evaluation of alternative sites for needle decompression of tension pneumothorax. Arch Surg. 2012;147(9):813-818. PMID 22987168.
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