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
  • 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

Emergent

Pediatric-specific

Non-Emergent

Evaluation

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 on M-mode (absence of "seashore" waves)

Management

  • 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

Disposition

  • Admit

Special Instructions

Flying

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

Complications

See Also

References

  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