Tension pneumothorax

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  • Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest

Clinical Features

  • Unilateral diminished or absent breath sounds
  • Hypotension or evidence of hypoperfusion
  • Distended neck veins
    • May not occur if patient is hypovolemic
  • Contralateral Tracheal deviation (late sign)
  • Type of obstructive shock since prevents venous return to the right side of the heart

Differential Diagnosis

Pneumothorax Types

Thoracic Trauma

Acute dyspnea




Left sided tension pneumothorax with mediastinal shift

Ideally a clinical diagnosis treated emergently (without delay for studies)

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)
  • 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)


  • Immediate needle thoracostomy
    • 14ga IV in midclavicular line just above the rib at the second intercostal space
  • Always followed by Chest Tube placement

Pediatric Chest Tube

  • Estimated as 4*ETT
    • 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)
  • Bronchial-pleural fistulae (large air leak)
  • Malignant fluid
Large (36-40 Fr)
  • Traumatic pneumothorax
    • 2012 study using 28-32 Fr tube just as good as 36-40 Fr tube. [1] This is reflected in the ATLS 2019 Guidelines: "ATLS ® -10 now recommends placement of a smaller 28F to 32F chest tube for any acute hemothorax that is visible on chest radiograph." [2]
  • Empyema
  • Bleeding (Hemothorax/hemopneumothorax)
  • Thick pus


  • Admit

Special Instructions


  • Can consider flying 2 weeks after full resolution of traumatic pneumothroax[3]


See Also


  1. Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
  2. Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.
  3. "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