tension pneumothorax by h scott bjerke, md, facs

8/12/2019 Tension Pneumothorax by H Scott Bjerke, MD, FACS

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emedicine.medscape.com

eMedicine Specialties > Trauma > Thoracic Trauma

Tension PneumothoraxH Scott Bjerke, MD, FACS,Clinical Associate Professor, Department of Surgery, University ofMissouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research MedicalCenter; Clinical Associate Professor, Department of Surgery, Indiana University School ofMedicine

Updated: May 15, 2009

Introduction

Tension pneumothorax is the accumulation of air under pressure in the pleural space. This

condition develops when injured tissue forms a 1-way valve, allowing air to enter the pleural

space and preventing the air from escaping naturally. Arising from numerous causes, this

condition rapidly progresses to respiratory insufficiency, cardiovascular collapse, and, ultimately,

death if unrecognized and untreated. Favorable patient outcomes require urgent diagnosis and

immediate management.

Tension pneumothorax is a clinical diagnosis that now is more readily recognized because of

improvements in emergency medical services (EMS) and the widespread use of chest x-rays

(see image below).
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The actual incidence of tension pneumothorax outside of a hospital setting is impossible to

determine. The 1999 revision of the Department of Transportation (DOT) Emergency Medical

Treatment (EMT) Paramedic curriculum recommends emergent needle decompression of the

chest in patients exhibiting nonspecific signs and symptoms. Approximately 10-30% of patients

transported to level-1 trauma centers in the US receive prehospital decompressive needlethoracostomies; however, not all of these patients actually have a true tension pneumothorax.

Although this occurrence rate may seem high, disregarding the diagnosis probably results in

unnecessary deaths.

The overall incidence of tension pneumothorax in the ICU is unknown. The medical literature

provides only glimpses of the frequency. From the 2000 incidents reported to the Australian

Incident Monitoring Study (AIMS), 17 involved actual or suspected pneumothoraces, and 4 of

those were diagnosed as tension pneumothorax. A more recent review of military deaths from

thoracic trauma suggests that up to 5% of combat casualties with thoracic trauma have tension

pneumothorax at the time of death.[1 ]

Etiology

The most common etiologies of tension pneumothorax are either iatrogenic or related to trauma.

They include the following:

Trauma (blunt or penetrating; see image below) Involves disruption of either the

visceral or parietal pleura and is often associated with rib fractures (rib fractures not

necessary for tension pneumothorax to occur)


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Image depicting multiple fractures of the left upper chest wall. The

first rib is often fractured posteriorly (black arrows). If multiple rib

fractures occur along the midlateral (red arrows) or anterior chest

wall (blue arrows), a flail chest (dotted black lines) may result.


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A patient in the intensive care unit (ICU) developed

pneumopericardium as a manifestation of barotrauma.

Central venous catheter placement, usually subclavian or internal jugular[2 ]

Conversion of idiopathic, spontaneous, simple pneumothorax to tension pneumothorax

Unsuccessful attempts to convert an open pneumothorax to a simple pneumothorax in

which the occlusive dressing functions as a 1-way valve

Chest compressions during cardiopulmonary resuscitation (CPR)

Pneumoperitoneum [3,4 ]

Fiberoptic bronchoscopy with closed-lung biopsy[5 ]

Markedly displaced thoracic spine fractures

In recent years, acupuncture has been reported to result in pneumothorax. [6,7,8 ]

Preexisting Bochdalek hernia with trauma[9 ]


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Colonoscopy[10 ]and gastroscopy have been implicated in case reports.

Percutaneous tracheostomy[11 ]

Pathophysiology

Tension pneumothorax occurs anytime a disruption involves the visceral pleura, parietal pleura,

or the tracheobronchial tree. The disruption occurs when a 1-way valve forms, allowing air

inflow into the pleural space and prohibiting air outflow. The volume of this nonabsorbable

intrapleural air increases with each inspiration because of the 1-way valve effect. As a result,

pressure rises within the affected hemithorax. As the pressure increases, the ipsilateral lung

collapses and causes hypoxia. Further pressure build-up causes the mediastinum to shift

toward the contralateral side and impinge on both the contralateral lung and the vasculature

entering the right atrium of the heart. This condition leads to worsening hypoxia and

compromised venous return. The inferior vena cava is thought to be the first to kink and restrict

blood flow back to the heart. It is most evident in trauma patients who may be hypovolemic with

reduced venous blood return to the heart.

Researchers still are debating the exact mechanism of cardiovascular collapse, but, generally,

they believe the condition develops from a combination of mechanical and hypoxic effects. The

mechanical effects manifest as kinking or compression of the superior and inferior vena cava

because the mediastinum deviates and the intrathoracic pressure increases. Hypoxia leads to

increased pulmonary vascular resistance via vasoconstriction. In either event, decreasing

cardiac output and worsening metabolic acidosis secondary to decreased oxygen delivery to the

periphery occur, thus inducing anaerobic metabolism. If the underlying problem remainsuntreated, the hypoxemia, metabolic acidosis, and decreased cardiac output lead to cardiac

arrest and death.

Presentation

Clinical interpretation of the presenting signs and symptoms of a tension pneumothorax is

crucial for diagnosing and treating the condition.

Early findings

o Chest paino Dyspnea

o Anxiety

o Tachypnea

o Tachycardia

o Hyperresonance of the chest wall on the affected side

o Diminished breath sounds on the affected side


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Late findings

o Decreased level of consciousness

o Tracheal deviation toward the contralateral side

o Hypotension

o Distention of neck veins (may not be present if hypotension is severe)o Cyanosis

These findings may be affected by the volume status of the patient. In hypovolemic trauma

patients with ongoing hemorrhage, the physical findings may lag behind the presentation of

shock and cardiopulmonary collapse.

In nonventilated patients, the diagnosis of tension pneumothorax often requires a high level of

suspicion and the presence of decreased or absent breath sounds on the affected side.

In ventilated patients, the physician may begin to suspect tension pneumothorax when

increased pleural pressures necessitate an increase in peak airway pressure in order to deliver

the same tidal volume. Decreased expiratory volumes secondary to air leakage into the pleural

space and increased end-expiratory pressure, even after discontinuation of PEEP, are 2 other

signs of tension pneumothorax in these patients. Occasionally, the development of tension

pneumothorax may be delayed for hours to days after the initial insult, and the diagnosis may

become evident only if the patient is receiving positive-pressure ventilation. Tension

pneumothorax has been reported during surgery with both single and double lumen tubes.

Increased pulmonary artery pressures and decreased cardiac output or cardiac index areevidence of tension pneumothorax in patients with Swan-Ganz catheters.

Indications

If signs and symptoms attributable to a clinical diagnosis of tension pneumothorax as noted

above (see Clinical) are present, aggressively manage with needle decompression of the chest.

Relevant Anatomy

Under emergency circumstances, place decompression catheters in the second rib interspace

in the midclavicular line. This has been confirmed by Wax and Leibowitz who reviewed 100

thoracic computed tomography (CT) scans measuring the distance from the midline to

the internal mammary artery and the average thickness of the tissues. [12 ]This

procedure punctures through the skin and, possibly, through the pectoralis major muscle,

external intercostals, internal intercostals, and parietal pleura. Placement in the middle third of


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the clavicle minimizes the risk of injury to the internal mammary artery during the emergency

procedure. Place the catheter just above the cephalad border of the rib, because the intercostal

vessels are largest on the lower edge of the rib.

Contraindications

If tension pneumothorax is suspected, make sure no contraindications exist for the placement of

an emergency decompression catheter into the thorax.

Contraindications can include previous thoracotomy, previous pneumonectomy, and the

presence of a coagulation disorder. These are relative contraindications, however, because

tension pneumothorax is a life-threatening condition, and failure to treat expectantly can result in

patient death.

Workup

Laboratory Studies

Although laboratory and imaging studies help determine a diagnosis, tension pneumothorax

primarily is a clinical diagnosis based on patient presentation. Do not delay delivery of treatment

modalities while waiting for imaging or laboratory studies.

Arterial blood gas (ABG) studies show varying degrees of acidemia, hypercarbia, and

hypoxemia, the occurrence of which depends on the extent of cardiopulmonary compromise at

the time of collection.

Imaging Studies

Suspicion of tension pneumothorax, especially in late stages, mandates immediate treatment

and does not require potentially prolonged diagnostic studies.

Ultrasonography provides a rapid imaging option for diagnosis of pneumothorax, but this

evaluation should NOT delay treatment of a clinically apparent tension pneumothorax.[13,14,15 ]

X-rays

X-rays showing tension pneumothorax often show 2 problems: first, the presence of tension

pneumothorax, and second, the fact that an x-ray procedure was performed rather than

emergent life-saving chest decompression (see the image below).


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This picture shows a chest radiograph with 2 abnormalities: (1) tension

pneumothorax and (2) potentially life-saving intervention delayed while

waiting for x-ray results. Tension pneumothorax is a clinical diagnosis

requiring emergent needle decompression, and therapy should never be

delayed for x-ray confirmation.

In the rare case that a chest x-ray is obtained safely, findings can include ipsilateral lung

collapse at the hilum, trachea and mediastinum deviation to the contralateral side, and widened

intercostal spaces on the affected side (see the images below). With a left hemithorax, the left

hemidiaphragm may be depressed, but the liver prevents this occurrence on the right side.


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Right main stem intubation resulting in left-sided tension pneumothorax,

right mediastinal shift, deep sulcus sign, and subpulmonic pneumothorax.

Treatment

Medical Therapy

No acceptable noninvasive therapy exists for this emergent life-threatening condition.

Surgical Therapy

Tension pneumothorax is a life-threatening condition that demands urgent management. If this

diagnosis is suspected, do not delay treatment in the interest of confirming the diagnosis.


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An older man was admitted to the intensive care unit (ICU)

postoperatively. Note the right-sided pneumothorax induced by the

incorrectly positioned small-bowel feeding tube in the right-sided bronchial

tree. Marked depression of the right hemidiaphragm is noted, and

mediastinal shift is to the left side, suggestive of tension pneumothorax.

The endotracheal tube is in a good position.


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Right main stem intubation resulting in left-sided tension pneumothorax,

right mediastinal shift, deep sulcus sign, and subpulmonic pneumothorax.

Monitor the patient continuously for arterial oxygen saturation.

Admit all patients with tension pneumothorax.

Emergent needle decompression

The basic principle or emergent needle decompression is to introduce a catheter into the pleural

space, thus producing a pathway for the air to escape and relieving the built-up pressure.

Although this procedure is not the definitive treatment for tension pneumothorax, emergent

needle decompression does arrest its progression and serves to restore cardiopulmonary


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function slightly. Needle length in persons with large pectoral muscles may be an issue, and

long needles or angiocatheters may be necessary. [16,17,18 ]

Administer 100% oxygen, and ventilate the patient if necessary.

Locate anatomic landmarks and quickly prepare the area to be punctured with an iodine-based

solution (eg, Betadine).

Insert a large-bore (ie, 14-gauge or 16-gauge) needle with a catheter into the second intercostal

space, just superior to the third rib at the midclavicular line, 1-2 cm from the sternal edge (ie, to

avoid injury to the internal thoracic artery). Use a catheter or needle >4.5 cm long, and hold it

perpendicular to the chest wall when inserting; however, note that some patients may have a

chest wall thickness greater than 4.5 cm, and failure for the symptoms to resolve may be

attributed to inadequate needle length.[16,17,18 ]

Once the needle is in the pleural space, listen for the hissing sound of air escaping, and remove

the needle while leaving the catheter in place.

Secure the catheter in place, and install a flutter valve.

Prepare the patient for tube thoracostomy.

Tube thoracostomy

Tube thoracostomy is the definitive treatment for tension pneumothorax, and needle

decompression mandates an immediate follow up with a tube thoracostomy.

Sedate the patient consciously; narcotics are optional and may not be necessary.

Locate anatomic landmarks, and administer a local anesthetic.

Prepare the area with an iodine solution (eg, Betadine) and drape.

Create a 3-cm horizontal incision in the skin, over the fifth or sixth rib along the midaxillary line.

Use a curved hemostat and dissect through the soft tissue and down to the rib.

Push the hemostat just over the superior portion of the rib, avoiding the intercostal

neurovascular bundle that runs under the inferior portion of the next most superior rib. Then,

puncture the intercostal muscles and parietal pleura.


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Recent data from the Iraqi conflict suggests that tension pneumothorax accounted for death in

3-4% of combat casualties unrelated to other injuries.[1 ]

Future and Controversies

No controversy surrounds the emergent decompression of symptomatic tension pneumothorax.

Improvement in the accuracy of diagnosis may change according to the changes in the 1999

DOT EMT Paramedic curriculum and the future availability of ultrasonographic technology for

use in the field. Studies performed for the National Aeronautics and Space Administration

(NASA) that are not yet published suggest that ultrasonography is useful in diagnosing

pneumothorax, making it potentially useful in emergency situations (eg, tension pneumothorax).

Multimedia

Media file 1: This picture shows a chest radiograph with 2 abnormalities:

(1) tension pneumothorax and (2) potentially life-saving intervention

delayed while waiting for x-ray results. Tension pneumothorax is a clinicaldiagnosis requiring emergent needle decompression, and therapy should

never be delayed for x-ray confirmation.


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Media file 4: A patient in the intensive care unit (ICU) developed

pneumopericardium as a manifestation of barotrauma.


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Media file 5: An older man was admitted to the intensive care unit (ICU)

postoperatively. Note the right-sided pneumothorax induced by the

incorrectly positioned small-bowel feeding tube in the right-sided bronchial

tree. Marked depression of the right hemidiaphragm is noted, and

mediastinal shift is to the left side, suggestive of tension pneumothorax.

The endotracheal tube is in a good position.


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Media file 6: Right main stem intubation resulting in left-sided tension

pneumothorax, right mediastinal shift, deep sulcus sign, and subpulmonic

pneumothorax.


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Media file 7: Subcutaneous Emphysema and Pneumothorax

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Keywords

tension pneumothorax, pneumothorax, collapsed lung, lung collapse, pneumomediastinum, air

in intrapleural space, blunt chest injury, penetrating chest injury, needle thoracostomy, tube

thoracostomy, chest tube, tension percutaneous aspiration, chest trauma, transthoracic needleaspiration, therapeutic thoracentesis, central venous catheter insertion, positive pressure

mechanical ventilation, intrapleural air, perivascular alveolar rupture

Contributor Information and Disclosures

Author

H Scott Bjerke, MD, FACS,Clinical Associate Professor, Department of Surgery, University of

Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research

Medical Center; Clinical Associate Professor, Department of Surgery, Indiana University Schoolof Medicine

H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association

for the History of Medicine, American Association for the Surgery of Trauma, American College

of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma,

Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical

Association, Royal Society of Medicine, Southwestern Surgical Congress, and Wilderness

Medical Society

Disclosure: Nothing to disclose.

Medical Editor

Marc D Basson, MD, PhD, MBA,Professor, Chair, Department of Surgery, Michigan State

University

Marc D Basson, MD, PhD, MBA is a member of the following medical societies: American

College of Surgeons and American Gastroenterological Association


Pharmacy Editor

Francisco Talavera, PharmD, PhD,Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Managing Editor

Robert L Sheridan, MD,Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns

Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and


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Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of

Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and

American College of Surgeons


CME Editor

Paolo Zamboni, MD,Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular

Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum

and New York Academy of Sciences


Chief Editor

John Geibel, MD, DSc, MA,Vice Chairman, Professor, Department of Surgery, Section of

Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University

School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven

Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American

Gastroenterological Association, American Physiological Society, American Society of

Nephrology, Association for Academic Surgery, International Society of Nephrology, New York

Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Other

Further ReadingRelated eMedicine Topics

Pneumomediastinum [in the Pediatrics: General Medicine section]

Pneumothorax [in the Pediatrics: General Medicine section]

Pneumothorax [in the Radiology section]

Pneumothorax [in the Thoracic Surgery section]

Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum [in the Emergency Medicinesection]

Pneumothorax, Tension and Traumatic [in the Emergency Medicine section]

Clinical Trials

Clinical Trial Evaluating the Optimal Technique for Chest Tube Removal

Drainage Amount for Removal of Thoracostomy Tube

Intrapleural Minocycline After Simple Aspiration for the Prevention of Primary SpontaneousPneumothorax

Management of Occult Pneumothoraces in Mechanically Ventilated Patients

Pneumothorax Therapy: Manual Aspiration Versus Conventional Chest Tube Drainage


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National Guideline Clearinghouse

ACR Appropriateness Criteria rib fractures. American College of Radiology - Medical SpecialtySociety. 1995 (revised 2005). 5 pages. [NGC Update Pending]NGC:004640

ACR Appropriateness Criteria routine chest radiograph. American College of Radiology - MedicalSpecialty Society. 2006. 6 pages. NGC:005540

Bronchoscopy assisting

2007 revision & update. American Association for Respiratory Care -Professional Association. 1993 Dec (revised 2007 Jan). 7 pages. NGC:005573

Differential diagnosis of chest pain. Finnish Medical Society Duodecim - Professional Association.2001 May 4 (revised 2008 May 16). Various pagings. NGC:006592

Guidelines on diagnosis and treatment of pulmonary arterial hypertension. The Task Force onDiagnosis and Treatment of Pulmonary Arterial Hypertension of the European Society of Cardiology.European Society of Cardiology - Medical Specialty Society. 2004. 36 pages. NGC:004058

Pain management in blunt thoracic trauma (BTT). Eastern Association for the Surgery of Trauma -Professional Association. 2004. 79 pages. NGC:004000

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tension pneumothorax by h scott bjerke, md, facs

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