Tension pneumothorax

Background

• 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
• Tracheal deviation (late sign)

Differential Diagnosis

Pneumothorax Types

• Tension pneumothorax
• Spontaneous pneumothorax
  • Catamenial pneumothorax
• Traumatic pneumothorax
  • Iatrogenic pneumothorax

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragmatic trauma
  • Hemothorax
  • Pneumomediastinum
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac injury
    • Blunt cardiac injury
      • Cardiac contusion
      • Commotio cordis
    • Penetrating cardiac injury
    • Cardiac tamponade
  • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Rib fracture
    • Flail chest
  • Scapular fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
  • Thoracic and lumbar fractures and dislocations
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Pneumopericardium
  • Traumatic asphyxia

Acute dyspnea

Emergent

• Pulmonary
  • Airway obstruction
  • Anaphylaxis
  • Angioedema
  • Aspiration
  • Asthma
  • Cor pulmonale
  • Inhalation exposure
  • Noncardiogenic pulmonary edema
  • Pneumonia
  • Pneumocystis Pneumonia (PCP)
  • Pulmonary embolism
  • Pulmonary hypertension
  • Tension pneumothorax
  • Idiopathic pulmonary fibrosis acute exacerbation
  • Cystic fibrosis exacerbation
• Cardiac
  • Cardiac tamponade
  • Cardiogenic pulmonary edema (CHF)
  • Myocardial Infarction
  • Pericarditis
  • Myocarditis
• Other Associated with Normal/↑ Respiratory Effort
  • Abdominal distension
  • Anemia
  • CO Poisoning
  • Salicylate toxicity
  • Diabetic ketoacidosis (DKA)
  • Diaphragm injury
  • Electrolyte abnormalities
  • Epiglottitis
  • Flail chest
  • Hypotension
  • Metabolic acidosis
  • Pneumonia
  • Pneumothorax/hemothorax
  • Renal Failure
  • Sepsis
  • Toxic ingestion
• Other Associated with ↓ Respiratory Effort
  • Guillain-Barre syndrome
  • Multiple sclerosis
  • Myasthenia Gravis
  • Lambert-Eaton Syndrome
  • Organophosphate toxicity
  • Stroke (Main)
  • Tick paralysis

Non-Emergent

• ALS
• Ascites
• Uncorrected ASD
• Congenital heart disease
• COPD exacerbation
• Fever
• Hyperventilation
• Interstitial lung disease
• Neoplasm
• Obesity
• Panic attack
• Pleural effusion
• Polymyositis
• Porphyria
• Pregnancy
• Rib fracture
• Spontaneous pneumothorax
• Thyroid Disease
• URI

Diagnosis

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

• CXR
• Ultrasound
  • Absence of lung sliding; absence of seashore (M-mode)
• CT chest
  • Most sensitive

Treatment

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

Adult Chest Tube Sizes

Chest Tube Size	Type of Patient	Underlying Causes
Small (8-14 Fr)	Most spontaneous pneumothorax (primary and secondary) Most iatrogenic pneumothorax	Alveolar-pleural fistulae (small air leak) Iatrogenic air
Medium (20-28 Fr)	Traumatic pneumothorax Traumatic hemothorax ("any acute hemothorax visible on chest radiograph") Pneumothorax on mechanical ventilation Non-traumatic tension pneumothorax Malignant effusion	Trauma/bleeding (hemothorax/hemopneumothorax) Bronchial-pleural fistulae (large air leak) Malignant fluid
Large (36-40 Fr)	Empyema	Thick pus

Disposition

• Admit

Special Instructions

Flying

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

See Also

• Pneumothorax (main)
• Chest Tube
• Thoracentesis
• Thoracic Trauma
• Hemothorax