Tension pneumothorax: Difference between revisions
(Expand with concise EM-focused content: clinical diagnosis emphasis, finger thoracostomy, needle failure rates)
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==Background==
==Background==
*Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest
*Pneumothorax with ongoing air leak creating a one-way valve mechanism → progressive accumulation of air under pressure in the pleural space
*Causes mediastinal shift, compression of contralateral lung, and impaired venous return → [[obstructive shock]] → cardiac arrest
*'''Death occurs from impaired venous return and hypoxia''' — this is a clinical diagnosis treated immediately without waiting for imaging
*Causes: penetrating or blunt [[thoracic trauma]], mechanical ventilation (barotrauma), central line placement, [[pneumothorax (main)|spontaneous pneumothorax]] with valve mechanism


==Clinical Features==
==Clinical Features==
*Unilateral diminished or absent breath sounds
*Unilateral diminished or absent breath sounds
*[[Hypotension]] or evidence of hypoperfusion
*[[Hypotension]] or hemodynamic instability (obstructive shock — impaired RV filling)
*Distended neck veins
*Distended neck veins (may not occur if patient is hypovolemic)
**May not occur if patient is hypovolemic
*Contralateral tracheal deviation ('''late finding''' — do not wait for this)
*Contralateral Tracheal deviation (late sign)
*[[Tachycardia]], [[tachypnea]], [[hypoxia]]
*Type of obstructive shock since prevents venous return to the right side of the heart
*[[Cardiac arrest]] ([[PEA]] or asystole) — always consider tension pneumothorax in traumatic arrest


==Differential Diagnosis==
==Differential Diagnosis==
{{Pneumothorax types}}
{{Pneumothorax types}}
{{Thoracic trauma DDX}}
{{Thoracic trauma DDX}}
{{SOB DDX}}


==Evaluation==
==Evaluation==
[[File:PMC2892654 CRM2010-213818.004.png|thumb|Left sided tension pneumothorax with mediastinal shift]]
[[File:PMC2892654 CRM2010-213818.004.png|thumb|Left sided tension pneumothorax with mediastinal shift]]
'''Ideally a clinical diagnosis treated emergently (without delay for studies)'''
'''This is a clinical diagnosis — do NOT delay treatment for imaging'''
*[[CXR]]
*[[CXR]] (if time permits and patient is stable): mediastinal shift, unilateral hyperlucency, deep sulcus sign
*[[Ultrasound: Lungs|Lung ultrasound]]
*[[Ultrasound: Lungs|Lung ultrasound]]: absent lung sliding on affected side (rapid bedside confirmation)
 
{{Lung ultrasound pneumothorax}}
{{Lung ultrasound pneumothorax}}


==Management==
==Management==
*Immediate [[needle thoracostomy]]
===Immediate Decompression===
**14ga IV in midclavicular line just above the rib at the second intercostal space
*'''Needle thoracostomy''' (decompression) — temporizing measure:
**Evidence suggests lowest failure rate of needle decompression is at the 4th/5th rib space along the anterior axillary line <ref>Laan DV et al. Chest Wall Thickness and Decompression Failure: A systematic Review and Meta-Analysis Coparing Anatomic Locations in Needle Thoracostomy. Injury 2015 [Epub Ahead of Print]. PMID: 26724173</ref>
**14-gauge angiocatheter, 2nd intercostal space midclavicular line (traditional)
*Always followed by [[Chest Tube]] placement
**Evidence suggests 4th-5th intercostal space at anterior axillary line has lower failure rate (less chest wall thickness)
'''Pediatric Chest Tube'''
**Failure rate with standard needle is up to 50% in obese or muscular patients
*Estimated as 4*ETT
*'''Finger thoracostomy''' — more reliable than needle decompression:
**ETT=(4+age/4)
**4th-5th intercostal space, anterior axillary line
**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===
*Adult: 28-36 Fr
*Pediatric: Estimated as 4 × ETT size (ETT = 4 + age/4)
{{Chest tube size table}}
{{Chest tube size table}}


==Disposition==
==Disposition==
*Admit
*Admit all patients after chest tube placement
 
*ICU if hemodynamically unstable or on mechanical ventilation
{{Flying instructions after pneumothorax}}
{{Flying instructions after pneumothorax}}


==Complications==
==Complications==
*[[Reexpansion pulmonary edema]]
*[[Reexpansion pulmonary edema]] (rare but serious)
*Tube malposition or dislodgement


==See Also==
==See Also==
*[[Pneumothorax (main)]]
*[[Pneumothorax (main)]]
*[[Needle thoracostomy]]
*[[Needle thoracostomy]]
*[[Finger Thoracostomy]]
*[[Finger thoracostomy]]
*[[Chest tube]]
*[[Adult pulseless arrest#Asystole and PEA (Non-Shockable)|Traumatic arrest]]
*[[Adult pulseless arrest#Asystole and PEA (Non-Shockable)|Traumatic arrest]]


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[[Category:Pulmonary]]
[[Category:Pulmonary]]
[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Critical Care]]

Revision as of 01:22, 21 March 2026

Background

  • Pneumothorax with ongoing air leak creating a one-way valve mechanism → progressive accumulation of air under pressure in the pleural space
  • Causes mediastinal shift, compression of contralateral lung, and impaired venous return → obstructive shock → cardiac arrest
  • Death occurs from impaired venous return and hypoxia — this is a clinical diagnosis treated immediately without waiting for imaging
  • Causes: penetrating or blunt thoracic trauma, mechanical ventilation (barotrauma), central line placement, spontaneous pneumothorax with valve mechanism

Clinical Features

  • Unilateral diminished or absent breath sounds
  • Hypotension or hemodynamic instability (obstructive shock — impaired RV filling)
  • Distended neck veins (may not occur if patient is hypovolemic)
  • Contralateral tracheal deviation (late finding — do not wait for this)
  • Tachycardia, tachypnea, hypoxia
  • Cardiac arrest (PEA or asystole) — always consider tension pneumothorax in traumatic arrest

Differential Diagnosis

Pneumothorax Types

The pleural cavity is normally a potential space, in which air collects in a pneumothorax.

Thoracic Trauma

Evaluation

Left sided tension pneumothorax with mediastinal shift

This is a clinical diagnosis — do NOT delay treatment for imaging

  • CXR (if time permits and patient is stable): mediastinal shift, unilateral hyperlucency, deep sulcus sign
  • Lung ultrasound: absent lung sliding on affected side (rapid bedside confirmation)

Lung ultrasound of pneumothorax

  • No lung sliding seen (not specific for pneumothorax)
  • May also identify "lung point": distinct point where you no longer see lung sliding (pathognomonic)
  • Absence of lung sliding WITHOUT lung point could represent apnea or right mainstem intubation
  • Evaluate other intercostal spaces because pneumothorax may only be seen in least dependent area of thorax
    • NO comet tail artifact
    • Bar Code appearance/"Stratosphere" sign on M-mode (absence of "seashore" waves)
  • Ultrasound has greater sensitivity than chest x-ray for pneumothorax in trauma patients [1]
  • Z-lines and lung sliding.png
  • No lung sliding.png
  • Lung sliding M mode.png
  • Lung point.gif

Management

Immediate Decompression

  • Needle thoracostomy (decompression) — temporizing measure:
    • 14-gauge angiocatheter, 2nd intercostal space midclavicular line (traditional)
    • Evidence suggests 4th-5th intercostal space at anterior axillary line has lower failure rate (less chest wall thickness)
    • Failure rate with standard needle is up to 50% in obese or muscular patients
  • Finger thoracostomy — more reliable than needle decompression:
    • 4th-5th intercostal space, anterior axillary line
    • 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

  • Adult: 28-36 Fr
  • Pediatric: Estimated as 4 × ETT size (ETT = 4 + age/4)

Adult Chest Tube Sizes

Chest Tube Size Type of Patient Underlying Causes
Small (8-14 Fr)
  • Alveolar-pleural fistulae (small air leak)
  • Iatrogenic air
Medium (20-28 Fr)
  • Trauma/bleeding (hemothorax/hemopneumothorax)
  • Bronchial-pleural fistulae (large air leak)
  • Malignant fluid
Large (36-40 Fr)
  • Thick pus

Disposition

  • Admit all patients after chest tube placement
  • ICU if hemodynamically unstable or on mechanical ventilation

Special Instructions

Flying

  • Can consider flying 2 weeks after full resolution of traumatic pneumothroax[4]

Complications

See Also

References

  1. ↑ Nagarsheth K, Kurek S. Ultrasound detection of pneumothorax compared with chest X-ray and computed tomography scan. Am Surg. 2011 Apr;77(4):480-4. PMID: 21679560.
  2. ↑ Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
  3. ↑ Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.
  4. ↑ "Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010" British Thoracic Society Guidelines. Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 PDF
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