Pneumothorax, Tension and Traumatic

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eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Pneumothorax, Tension and TraumaticJeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio

Updated: May 27, 2010

Introduction

Background

A pneumothorax refers to a collection of gas in the pleural space resulting in collapse of the lung

on the affected side. A tension pneumothorax is a life-threatening condition caused by air within

the pleural space that is under pressure; displacing mediastinal structures and compromising

cardiopulmonary function. A traumatic pneumothorax results from blunt or penetrating injury that

disrupts the parietal or visceral pleura. Mechanisms include injuries secondary to medical or

surgical procedures.

Pneumothorax is shown in the image below.

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Pneumothorax, Tension and Traumatic.

Pathophysiology

A tension pneumothorax results from any lung parenchymal or bronchial injury that acts as a

one-way valve and allows free air to move into an intact pleural space but prevents the free exit

of that air. In addition to this mechanism, the positive pressure used with mechanical ventilation

therapy can cause air trapping.

As pressure within the intrapleural space increases, the heart and mediastinal structures are

pushed to the contralateral side. The mediastinum impinges on and compresses the

contralateral lung.

Hypoxia results as the collapsed lung on the affected side and the compressed lung on the

contralateral side compromise effective gas exchange. This hypoxia and decreased venous

return caused by compression of the relatively thin walls of the atria impair cardiac function. The

decrease in cardiac output results in hypotension and, ultimately, in hemodynamic collapse and

death to the patient, if untreated.

Frequency

United States

A study conducted from 1959-1978 involving a US community with an average of 60,000

residents reported an incidence of primary spontaneous pneumothorax of 7.4 cases per

100,000 persons per year for men and 1.2 cases per 100,000 persons per year for women.

When these figures are extrapolated, about 8,600 individuals develop primary spontaneous

pneumothorax in the United States per year.

Tension pneumothorax is a complication in approximately 1-2% of the cases of idiopathic

spontaneous pneumothorax. Until the late 1800s, tuberculosis was a primary cause of

pneumothorax development. A 1962 study showed a frequency of pneumothorax of 1.4% in

patients with tuberculosis.

Undoubtedly, the incidence of pneumothorax and/or tension pneumothorax in US hospitals has

increased as intensive care treatment modalities have become increasingly dependent on

positive-pressure ventilation, central venous catheter placement, and other causes that

potentially induce iatrogenic pneumothorax.

International

Acupuncture is a traditional Chinese medicine technique used worldwide by alternative medical

practitioners. Although generally considered to be a safe form of therapy, acupuncture's most

frequently reported serious complication is pneumothorax. In one Japanese report of 55,291

acupuncture treatments, an approximate incidence of 1 pneumothorax in 5000 cases was

documented.[1 ]

Mortality/Morbidity

The clinician should assume that a tension pneumothorax results in hemodynamic instability

and death, unless immediately treated.

Sex

The male-to-female ratio is about 6:1 for primary spontaneous pneumothorax development.

In men, the risk of spontaneous pneumothorax is 102 times higher in heavy smokers

than in nonsmokers. Spontaneous pneumothorax most frequently occurs in tall, thin men

aged 20-40 years.

Catamenial pneumothorax is a rare phenomenon that generally occurs in women aged

30-50 years. It frequently begins 1-3 days after menses onset. Its etiology may be

primarily related to associated diaphragmatic defects.

Men undergoing treatment for tension pneumothorax are more likely to have a larger body

habitus with wider chest wall. Tension pneumothorax patients with wider chest walls undergoing

needle thoracostomy may need a catheter longer than 5 cm to reliably penetrate into the pleural

space.

Harcke et al using CT scan analysis of deployed male military personnel determined that, at the

second right intercostal space in the midclavicular line, the mean horizontal thickness was 5.36

cm, and that an 8-cm angiocatheter would reach the pleural space in 99% of the male soldiers

in this series.[2 ]

Age

Pneumothorax occurs in 1-2% of all neonates. The incidence of pneumothorax in infants with

neonatal respiratory distress syndrome is higher. In one study, 19% of such patients developed

a pneumothorax.

Clinical

History

The signs and symptoms produced by tension pneumothorax are usually more impressive than

those seen with a simple pneumothorax. Unlike the obvious patient presentations oftentimes

used in medical training courses to describe a tension pneumothorax, actual case reports

include descriptions of the diagnosis of the condition being missed or delayed because of subtle

presentations that do not always present with the classically described clinical findings of this

condition.

Symptoms and signs of tension pneumothorax may include the following:

Chest pain (90%)

Dyspnea (80%)

Anxiety

Acute epigastric pain (a rare finding)

Fatigue

Physical

Findings at physical examination may include the following:

Respiratory distress (considered a universal finding) or respiratory arrest

Unilaterally decreased or absent lung sounds (a common finding; but decreased air

entry may be absent even in an advanced state of the disease)

Adventitious lung sounds (crackles, wheeze; an ipsilateral finding)

Lung sounds transmitted from the nonaffected hemithorax are minimal with auscultation

at the midaxillary line

Tachypnea; bradypnea (as a preterminal event)

Hyperresonance of the chest wall on percussion (a rare finding; may be absent even in

an advanced state of the disease)

Hyperexpansion of the chest wall

Increasing resistance to providing adequate ventilation assistance

Cyanosis (a rare finding)

Tachycardia (a common finding)

Hypotension (should be considered as an inconsistently present finding; while

hypotension is typically considered as a key sign of a tension pneumothorax, studies

suggest that hypotension can be delayed until its appearance immediately precedes

cardiovascular collapse)

Pulsus paradoxus

Jugular venous distension

Cardiac apical displacement (a rare finding)

Tracheal deviation (an inconsistent finding; while historic emphasis has been placed on

tracheal deviation in the setting of tension pneumothorax, tracheal deviation is a

relatively late finding caused by midline shift)

Mental status changes, including decreased alertness and/or consciousness (a rare

finding)

Abdominal distension (from increased pressure in the thoracic cavity producing caudal

deviation of the diaphragm and from secondary pneumoperitoneum produced as air

dissects across the diaphragm through the pores of Kohn)

When examining a patient for suspected tension pneumothorax, helpful indications of

subtle thoracic size and thoracic mobility differences may be elicited by performing

careful visual inspection along the line of the thorax. In a supine patient, by lowering

oneself to be in level with the patient.

Tension pneumothorax may be a difficult diagnosis to make and may present with

considerable variability in signs presented. Respiratory distress and chest pain are

generally accepted as being universally present in tension pneumothorax. Tachycardia

and ipsilateral air entry are also common findings.

The development of tension pneumothorax in patients who are ventilated will generally

be of faster onset with immediate, progressive arterial and mixed venous oxyhemoglobin

saturation decline and immediate decline in cardiac output.

Cardiac arrest associated with asystole or pulseless electrical activity (PEA) may

ultimately result.

Causes

A wide variety of disease states and circumstances increase the patient's risk of a

pneumothorax. If a pneumothorax is complicated by a one-way valve effect, tension

pneumothorax may result.

Infants requiring ventilatory assistance and those with meconium aspiration have a

particularly high risk for tension pneumothorax. Aspirated meconium may serve as a

one-way valve and produce a tension pneumothorax.

Trauma may cause a pneumothorax.

o Tension pneumothorax may be the result of blunt trauma with or without

associated rib fractures.

o Incidents that may cause tension pneumothoraces include unrestrained head-on

motor vehicle accidents, falls, and altercations involving laterally directed blows.

o Any penetrating wound that produces an abnormal passageway for gas

exchange into the pleural spaces and that results in air trapping may produce a

tension pneumothorax.

o Significant chest injuries carry an estimated 10-50% risk of associated

pneumothorax. In about half of these cases, the pneumothorax may be occult;

therefore, chest CT should always be performed.

o In one study, 12% of patients with asymptomatic chest stab wounds had a

delayed pneumothorax or hemothorax.

o McPherson et al, analyzing data from the Vietnam Wound Data and Munitions

Effectiveness Team study, determined that tension pneumothorax was the cause

of death in 3-4% of fatally wounded combat casualties.[3 ]

Many procedures performed in an intensive care or emergency setting can result in an

iatrogenic pneumothorax and tension pneumothorax. Examples of these procedures

include incorrect chest tube insertion, mechanical ventilation therapy, central venous

cannulation; cardiopulmonary resuscitation; hyperbaric oxygen therapy; needle,

transbronchial, or transthoracic lung biopsy; liver biopsy or surgery; and neck surgery.

Secondary or spontaneous tension pneumothorax is possible in many medical

conditions.

o Pneumothorax is associated with asthma, chronic obstructive pulmonary

disease, pneumonia (especially with Staphylococcus, Klebsiella,

Pseudomonas, and Pneumocystis species), pertussis, tuberculosis, lung

abscess, and cystic fibrosis.

o In pulmonary disorders such as asthma and emphysema, hyperexpansion

disrupts the alveoli.

o Increased pulmonary pressure due to coughing with a bronchial plug of mucus or

phlegm bronchial plug may play a role.

o Marfan syndrome is associated with an increased risk of pneumothorax.

o Individuals may inherit a predisposition for primary spontaneous pneumothorax.

o Although rare, spontaneous pneumothorax occurring bilaterally and progressing

to tension pneumothorax has been documented.

Differential Diagnoses

Acute Coronary Syndrome Pediatrics, Pneumonia

Acute Respiratory Distress Syndrome

Pericarditis and Cardiac Tamponade

Anxiety Pneumonia, Aspiration

Asthma Pneumonia, Bacterial

Congestive Heart Failure and Pulmonary Edema

Pneumonia, Empyema and Abscess

Diaphragmatic Injuries Pneumonia, Immunocompromised

Dissection, Aortic Pneumonia, Mycoplasma

Esophageal Perforation, Rupture and Tears

Pneumonia, Viral

Foreign Bodies, Trachea Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum

Myocardial Infarction Tuberculosis

Pediatrics, Pertussis

Other Problems to Be Considered

Airway obstruction

Hemothorax

Workup

Laboratory Studies

ABG analysis does not replace physical diagnosis nor should treatment be delayed while

awaiting results if symptomatic pneumothorax is suspected. However, ABG analysis may be

useful in evaluating hypoxia and hypercarbia and respiratory acidosis.

Imaging Studies

Translumination: In neonatal patients, one may notice increased transmission of light

through the chest on the affected side.

Chest radiography: Historical dogma has included the recommendation that a chest

radiograph of tension pneumothorax is a film that should never be taken. In addition, as

ultrasonography becomes increasingly available in emergency situations, the already

limited role of radiography will be even further minimized. Multiple recent studies have

shown bedside ultrasonography to be more accurate than supine chest radiography in

detecting and quantifying the presence of pneumothorax, including traumatic

pneumothorax. When considering radiography, utilizing a risk-benefit analysis has been

suggested, in which the time taken to obtain the radiograph is balanced against the

expected clinical course, with decompression preceding chest radiography in ventilated

patients who are prone to rapid decompensation.

o In a select subset of patients, it may be preferable to radiologically confirm and

localize tension pneumothorax before subjecting the patient to potential

morbidities arising from decompression. However, this consideration should be

limited to a subset of patients who are awake, stable, not in advanced stages of

tension and when an immediate chest film can be obtained, with a continuously

accompanying practitioner ready to perform urgent decompression should the

need arise.

o Although the initial chest radiograph may show no evidence of pneumothorax,

consider the possibility of delayed traumatic pneumothorax development in any

penetrating chest wound. Obtain serial chest radiographs every 6 hours the first

day after injury to rule this out. Some authors advocate the acquisition of only

one or two serial examinations every 4-6 hours.

o Air in the pleural cavity, with contralateral deviation of mediastinal structures, is

evidence of a tension pneumothorax. Tension pneumothorax chest radiographic

findings may include increased thoracic volume, increased rib separation, heart

border ipsilateral flattening, contralateral mediastinal deviation, and

hemidiaphragmatic depression.

o Pneumothorax chest radiograph findings include ipsilateral lung edge seen

parallel to the chest wall, increased lucency, and a deep sulcus sign (deep lateral

costophrenic angle).

o When evaluating the chest radiograph for pneumothorax, assess rotation.

Rotation can obscure a pneumothorax and mimic a mediastinal shift.

o In evaluating the radiograph for rotation, compare the symmetry and shape of the

clavicles. Also, look at the relative lengths of the ribs in the middle lung fields on

each side on the anteroposterior or posteroanterior views. On an image with

rotation, the ribs on each side often have unequal lengths.

o In a nonloculated pneumothorax, air rises to the nondependent portion of the

pleural cavity. Therefore, carefully examine the apices of an upright chest

radiograph, and scrutinize the costophrenic and cardiophrenic angles on a

supine chest radiograph.

o A skin fold can be mistaken for a pneumothorax. Unlike pneumothoraces, skin

folds usually continue beyond the chest wall, and lung markings can be seen

peripheral to the skin fold line. Viewing the film under the hot lamp may be

necessary to discern obscure peripheral lung markings.

o In evaluating the chest radiograph, first impressions of pneumothorax size can be

misleading. To assist in determining the size of pneumothorax on the radiograph,

a 2.5-cm margin of gas peripheral to the collapsing lung corresponds to a

pneumothorax of about 30%. Complete collapse of the lung is a 100%

pneumothorax.

Chest CT scanning

o Collapse of the lung, air in the pleural cavity, and deviation of mediastinal

structures are present in tension pneumothorax.

o A CT scan is more sensitive than a chest radiograph in the evaluation of small

pneumothoraces and pneumomediastinum, although the clinical significance of

these occult pneumothoraces is unclear, particularly in the stable nonintubated

patient.

o A CT scan may allow for further evaluation of underlying pulmonary disease or

injury.

Ultrasonography

o Use of bedside ultrasonography in the diagnosis of pneumothorax is a relatively

recent development. In some trauma centers, pneumothorax detection is

included as part of their focused abdominal sonography for trauma (FAST)

examination. Knudtson et al, in a prospective analysis of 328 consecutive trauma

patients at a level 1 trauma center, obtained a specificity of 99.7% and an

accuracy of 99.4%, and concluded that ultrasonography was a reliable modality

for the diagnosis of pneumothorax in the injured patient.[4 ]

o Ultrasonographic features used in the diagnosis of pneumothorax include

absence of lung sliding (high sensitivity and specificity), absence of comet-tail

artifact (high sensitivity, lower specificity), and presence of lung point (high

specificity, lower sensitivity). In the absence of pleural disease, visceral pleura

moves against parietal pleura while breathing. This movement of the two pleura

is detected by the ultrasound as lung sliding, which is a "kind of twinkling

synchronized with respiration" seen in real-time and time-motion modes. Comet-

tail artifacts are vertical air artifacts that arise from the visceral pleural line (or in

the case of parietal emphysema or shotgun pellets may arise above the pleural

line).

o Lung point, the location that lung-sliding and absent lung-sliding alternately

appear, has been shown in multiple studies to allow determination of the size of a

pneumothorax. Zhang et al obtained a 79% sensitivity in lung point's ability to

determine pneumothorax size.[5 ]

o In one study, ultrasonography had 95.5% sensitivity and 100% specificity for

pneumothorax detection compared with chest radiography. In another study,

ultrasonography performed on patients with blunt thoracic trauma had 94%

sensitivity and 100% specificity for pneumothorax detection compared with spiral

CT scanning. A prospective study involving 135 patients with multiple trauma

using bedside ultrasonography performed by emergency department clinicians

obtained 86% sensitivity and 97% specificity for the detection of pneumothorax.

o A prospective study by Brook et al was designed to assess the accuracy of

radiology residents in detecting pneumothoraces as part of the extended focused

assessment with sonography for trauma (eFAST). Comparing sonographic

pneumothorax detection (by the absence of parietal-over-visceral lung sliding

with "comet tail" artifacts behind it) with the reference standard of chest CT in

169 consecutive trauma patients (ie, 338 lung fields) demonstrated a sensitivity

of 47%, specificity of 99%, positive predictive value of 87%, and negative

predictive value of 93%; with none of the small pneumothoraces missed by

ultrasound requiring drainage during the hospitalization period. The authors

concluded that sonographic pneumothorax detection by these radiology residents

was both accurate and efficient in the early detection of clinically important

pneumothoraces.[6 ]

Procedures

Needle thoracostomy is performed as follows:

o Locate puncture site. The second intercostal space in the midclavicular line on

the affected side immediately superior to the rib is most commonly recommended

site.

o Prepare the puncture site with povidone-iodine (Betadine), alcohol scrubs, or

both.

o Insert a large-bore Angiocath (14-gauge in an adult, 18- or 20-gauge in an infant)

into the desired intercostal space over the top of the rib and perpendicular to the

chest wall. Listen for a rush of air.

o Remove the needle.

o Secure the Angiocath in place, and establish a water seal or flutter valve.

o Immediately prepare to insert a chest tube.

o Listen for a rush of air on insertion to confirm the diagnosis of tension

pneumothorax. Note this finding on the patient's chart. In an area with high

ambient noise, the escape of air may not be detected.

o Needle thoracostomy requires follow-up placement of a chest tube.

o Potential morbidity associated with needle thoracostomy includes pneumothorax

(with potential to tension later), cardiac tamponade, hemorrhage (which can be

life-threatening), loculated intrapleural hematoma, atelectasis, pneumonia,

arterial air embolism (when needle thoracostomy is performed and no tension

pneumothorax is present), and pain to the patient.

Tube thoracostomy is performed as follows:

o If the patient is hemodynamically stable, consider conscious sedation with careful

titration of a short-acting narcotic and benzodiazepine. However, use of a local

anesthetic often is adequate.

o Place the patient in a 30-60° reverse Trendelenburg position, scrub the site with

povidone-iodine (Betadine), alcohol, or both, and anesthetize the site with

lidocaine.

o Make a 3- to 4-cm incision over the fifth or sixth rib in the midaxillary line.

o Use a curved hemostat to puncture the intercostal muscles and parietal pleura

immediately superior to the rib border, avoiding damage to the underlying lung.

Then, slide a finger over the clamp to maintain the formed tract.

o Perform a digital examination to assess the location and to evaluate pulmonary

adhesions. Sweep the finger in all directions, and feel for the diaphragm and

possible intra-abdominal structures. To avoid losing the desired tract, keep the

finger in place until the tube is inserted.

o Insert the chest tube along side of the finger, using a clamp on the tube, if

desired.

o Direct the chest tube posteriorly and inferiorly, and insert it until it is at least 5 cm

beyond the last hole of the tube.

o Attach the tube to a water seal and vacuum device (eg, Pleur-Evac). Look for

respiratory variation and bubbling of air through the water seal. Document the

amount of blood or other fluids that may drain.

o Suture the site, and secure the tube. A variety of anchoring and closure

techniques exist, all of which are probably equivalent. Cover the site with

petroleum jelly–impregnated gauze, and apply a suitable dressing.

o Follow-up chest radiography is required to confirm tube placement and lung

reexpansion.

o Complications of tube thoracostomy include death, injury to lung or mediastinum,

hemorrhage (usually from intercostal artery injury), neurovascular bundle injury,

infection, bronchopleural fistula, and subcutaneous or intraperitoneal tube

placement.

Treatment

Prehospital Care

Attention to the ABCs is mandatory for all patients with thoracic trauma. Evaluate the patency of

the airway and the adequacy of the ventilatory effort. Assess the circulatory status and the

integrity of the chest wall.

Failure of the emergency medical service personnel and medical control physician to

make a correct diagnosis of tension pneumothorax and to promptly perform needle

decompression in the prehospital setting can result in rapid clinical deterioration and

cardiac arrest.

However, if an incorrect diagnosis of tension pneumothorax is made in the prehospital

setting, the patient's life is endangered by unnecessary invasive procedures. Close

cooperation and accurate communication between the emergency department and the

emergency medical service personnel is of paramount importance.

To prevent reentry of air into the pleural cavity after needle thoracostomy and

decompression in the prehospital setting, a one-way valve should be attached to the

distal end of the Angiocath. If available, a Heimlich valve may be used. If a commercially

prepared valve is not available, attach a finger condom or the finger of a rubber glove

with its tip removed to serve as a makeshift one-way valve device.

Clothing covering a wound that communicates with the chest cavity can play a role in

producing a one-way valve effect, allowing air to enter the pleural cavity but hindering its

exit. Removing such clothing items from the wound may facilitate decompression of a

tension pneumothorax.

A tension pneumothorax is a contraindication to the use of military antishock trousers.

In a preliminary 2006 study from Norway, Busch evaluated the feasibility of using portable

ultrasound in an air rescue setting.[7 ]Concluding that prehospital ultrasonography could provide

diagnostic and therapeutic benefit when conducted by a proficient examiner who used goal-

directed and time-sensitive protocols. Further study in this area may help to determine the

indications and role of prehospital sonography.

Emergency Department Care

For all patients with thoracic injury, immediate and careful attention to the ABCs is vital. Fully

assess the patency of the airway and adequacy of the ventilatory effort. Carefully evaluate the

cardiovascular system because a tension pneumothorax and a pericardial tamponade can

cause similar findings.

If a tension pneumothorax is suspected, immediately administer 100% oxygen, and

evaluate the patient for evidence of respiratory compromise, hemodynamic instability, or

clinical deterioration. Place large-bore catheters, because hemothorax can be

associated with pneumothorax, and the patient may, therefore, require immediate

intravenous infusion. Upright positioning, if not inappropriate due to cervical spine or

trauma concerns, may be beneficial.

Immediately perform needle thoracostomy or chest tube placement (see Procedures) if

the clinical condition warrants such action. Once a needle thoracostomy has been

performed, chest tube insertion must follow.

If a hemothorax is associated with the pneumothorax, additional chest tubes may be

needed to assist drainage of blood and clots. If the hemopneumothorax requires

insertion of a second chest tube, the second tube should be directed inferiorly and

should be posterior to the diaphragm.

Chest tubes are attached to a vacuum apparatus that continually removes air from the

pleural cavity. The collapsed lung reexpands and heals, thereby preventing continued air

leakage. After air leaks have ceased for 24 hours, the vacuum may be decreased and

the chest tube removed.

The process of lung reexpansion and healing is not immediate and may be complicated

by pulmonary edema; therefore, a chest tube is usually left in place for at least 3 days

unless the clinical condition warrants a longer placement.

In general, traumatic pneumothoraces should be treated with insertion of a chest tube,

particularly if the patient cannot be closely observed. A subset of patients who have a

small (<15-20%), minimally symptomatic pneumothorax may be admitted, observed

closely, and monitored by using serial chest radiographs. In these patients,

administration of 100% oxygen promotes resolution by speeding the absorption of gas

from the pleural cavity into the pulmonary vasculature.

Hernandez et al noted that ultrasonography is the only radiographic modality allowing patients

with nonarrhythmogenic cardiac arrest to continue undergoing resuscitation while searching for

easily reversible causes of asystole or PEA.[8 ]Their proposal is for further investigation into a

protocol (using the acronym C.A.U.S.E. for cardiac arrest ultrasound exam) in which cardiac

arrest patients, concurrent with resuscitation, receive bedside ultrasonography to look for

cardiac tamponade, massive pulmonary embolus, severe hypovolemia, and tension

pneumothorax. Their hope is that the eventual adoption of ultrasonography in this setting may

allow increased "real-time" diagnostic acumen, decreasing the time required to receive

appropriate condition-related therapy.

Consultations

Treatment of tension pneumothorax should commence immediately after diagnosis,

without waiting for further consultation and/or evaluation.

A trauma or general surgeon should evaluate patients with trauma, and the patient

should be admitted for observation.

Medication

A tension pneumothorax requires treatment with procedural modalities. Anesthetics and

analgesics should be used if the patient is not in distress. Medication may be necessary to treat

the pulmonary disorder that caused the pneumothorax. For example, intravenous antibiotics are

included in the treatment of a pneumothorax that developed as a sequela of staphylococcal

pneumonia. Also, studies suggest that the administration of prophylactic antibiotics after chest

tube insertion may reduce the incidence of complications such as emphysema.

Follow-up

Further Inpatient Care

If the patient has had repeated episodes of pneumothorax or if the lung remains

unexpanded after 5 days with a chest tube in place, surgery may be necessary. The

surgeon may use treatment options such as thoracoscopy, electrocautery, laser

treatment, resection of blebs or pleura, or open thoracotomy.

In patients with repeated pneumothoraces who are not good candidates for surgery,

sclerotherapy with talc or doxycycline may be necessary.

In a preliminary study by Dente et al, ultrasonographic evaluation for pneumothorax was

found to be very accurate for the first 24 hours after insertion of a thoracostomy tube.

However, its accuracy is not sustained over time. Twenty-four hours after thoracostomy,

diagnostic sensitivity of ultrasonography for pneumothorax fell to 55%, and its positive

predictive value to 43%. This may be related to intrapleural adhesion formation.[9 ]

Deterrence/Prevention

Advise patients to wear safety belts and passive restraint devices while driving.

Encourage smoking cessation.

The incidence of iatrogenic tension pneumothorax may be decreased with prophylactic

insertion of a chest tube in patients with a simple pneumothorax that requires positive

pressure ventilation.

When subclavian vein cannulation is required, use the supraclavicular approach rather

than the infraclavicular approach when possible to help decrease the likelihood of

pneumothorax formation.

Prompt recognition and treatment of bronchopulmonary infections decreases the risk of

progression to a pneumothorax.

Complications

Complications of tension or traumatic pneumothorax may include the following:

Respiratory distress and/or arrest

Cardiac arrest

Pulmonary edema (following lung reexpansion)

Empyema

Persistent bronchopulmonary fistula

Pneumomediastinum

Pneumopericardium

Pneumoperitoneum

Pyopneumothorax

Hemopneumothorax

Prognosis

The prognosis is generally good with appropriate therapy, but it varies depending on the

etiology.

Miscellaneous

Medicolegal Pitfalls

The diagnosis of a tension pneumothorax should largely be made based on the history

and physical examination findings. Ultrasonography in the emergency setting is being

increasingly used as an adjunct to the physical examination when there is doubt

regarding the diagnosis. Chest radiography or CT scanning should be used only in those

instances when the clinician is in doubt regarding the diagnosis and when the patient's

clinical condition is sufficiently stable. Obtaining such imaging studies when the

diagnosis of tension pneumothorax is not in question causes an unnecessary and

potentially lethal delay in treatment.

A tension pneumothorax is a life-threatening condition and requires immediate action

(eg, needle thoracostomy or chest tube insertion). However, the clinician should be wary

of prematurely diagnosing a tension pneumothorax in a patient without respiratory

distress, hypoxia, hypotension, or cardiopulmonary compromise. If the patient's clinical

presentation is questionable and if the patient appears stable, the clinician should

reexamine the patient and use bedside ultrasonography or request immediate portable

chest radiography (or reexamine the chest radiographs if they have already been

obtained) to confirm the diagnosis.

Consider the diagnosis of a pneumothorax and/or tension pneumothorax with blunt and

penetrating trauma. In the patient with blunt trauma and mental status changes, hypoxia,

and acidosis, symptoms may be attributed to a suspected intracerebral injury rather than

a tension pneumothorax. Portable chest radiography should always be included in the

initial radiographic evaluation of major trauma. Chest CT scanning should always be

performed for significant chest injuries since they carry an estimated risk of associated

pneumothorax as high as 50% and about half of these pneumothoraces may be occult.

When assessing the trauma patient, be aware that clinical presentations of tension

pneumothorax and myocardial rupture with tamponade may be similar.

The rare event of spontaneous pneumothorax leading to tension pneumothorax may be

misdiagnosed as an asthma crisis or COPD exacerbation in the patient presenting with

tachycardia, subcutaneous emphysema, dyspnea, and shock.

A significant number of patients have a larger chest wall than can be penetrated by a

catheter length of 5 cm. Although thinner patients requiring thoracostomy can be treated

using shorter catheter lengths, patients with a body habitus suggestive of a wider chest

wall may need a catheter longer than 5 cm to reliably penetrate into the pleural space. In

one study, a catheter length of patients at an American level 1 trauma center showed

that a catheter length of 5 cm would reliably penetrate the pleural space in only 75% of

patients.[10 ]A 2008 study analyzing average chest wall thickness at the second intercostal

space in the midclavicular line concluded that a 4.5-cm catheter length may not

penetrate the chest wall in approximately 10-35% of trauma patients, depending on age

and gender.[11 ]

Maintain a high index of suspicion for a tension pneumothorax in patients using

ventilators who have a rapid onset of hemodynamic instability or cardiac arrest,

particularly if they require increasing peak inspiratory pressures. Patients at greatest risk

of a pneumothorax and/or tension pneumothorax include those with COPD who are

using ventilators; those with acute respiratory distress syndrome; and those requiring a

tidal volume greater than 12 mL/kg, a peak airway pressure greater than 60 cm H2 O, or

a positive end-expiratory pressure greater than 15 cm H2 O.

Avoid assuming that a patient with a chest tube does not have a tension pneumothorax if

he or she has respiratory or hemodynamic instability. Chest tubes can become plugged

or malpositioned and cease to function. In addition, improper attachment of a one-way

valve to the chest tube may produce tension pneumothorax.

A 2005 study of emergency physicians used a sampling of 25 emergency physicians, 21

of which had completed ATLS training. When attempting to correctly locate the needle

thoracostomy site on a human volunteer, only 60% were able to correctly identify the

second intercostal space, and all placed the thoracentesis needle medial to the

midclavicular line. In this same study, 8% of participants inappropriately identified the

site used for needle pericardiocentesis and 4% inappropriately identified the fifth

intercostal space in the anterior axillary line.[12 ]

Related to the development of apparent life-threatening hemorrhage after

decompression in the second intercostal space at the anterior, midclavicular line in

patients with no initial evidence of hemothorax on presentation, it has been suggested

that a potentially safer option is to decompress a pneumothorax in the fifth intercostal

space at the anterior axillary line, similar to recommendations for chest drain insertion.

Multimedia

Media file 1: Pneumothorax, Tension and Traumatic.

Media file 7: Subcutaneous emphysema and pneumothorax.

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Keywords

pneumothorax, tension pneumothorax, traumatic pneumothorax, pleural gas, idiopathic

spontaneous pneumothorax, tuberculosis, iatrogenic pneumothorax, catamenial pneumothorax,

respiratory distress, cyanosis, chest trauma, penetrating wound

chest stab wounds, mechanical ventilation therapy, central venous cannulation,

cardiopulmonary resuscitation, hyperbaric oxygen therapy, transbronchial lung biopsy,

transthoracic lung biopsy, liver biopsy, liver surgery, neck surgery, asthma, chronic obstructive

pulmonary disease, Staphylococcus pneumonia, Klebsiella pneumonia, Pseudomonas

pneumonia, Pneumocystis pneumonia, pertussis, lung abscess, cystic fibrosis, emphysema,

Marfan syndrome

Contributor Information and Disclosures

Author

Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio

Disclosure: Nothing to disclose.

Medical Editor

Joseph A Salomone III, MD, Associate Professor and Attending Staff, Truman Medical

Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas

City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy

of Emergency Medicine, National Association of EMS Physicians, and Society for Academic

Emergency Medicine


Pharmacy Editor

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

Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Legome, MD, Chief, Department of Emergency Medicine, Kings County Hospital Center;

Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha,

American Academy of Emergency Medicine, American College of Emergency Physicians,

Council of Emergency Medicine Residency Directors, and Society for Academic Emergency

Medicine


CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth

Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and

Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel

Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of

Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society

for Academic Emergency Medicine


Chief Editor

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Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha,

American Academy of Emergency Medicine, American College of Emergency Physicians,

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