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, Tension and Traumatic.

Signs and symptoms

Pneumothorax presents mainly as a sudden shortness of breath, dry coughs, cyanosis (turning blue) and pain felt in
the chest, back and/or arms. In penetrating chest wounds, the sound of air flowing through the puncture hole may
indicate pneumothorax, hence the term "sucking" chest wound. The flopping sound of a punctured lung is also
occasionally heard. Subcutaneous emphysema is another symptom.

If untreated, hypoxia may lead to hypercapnia, respiratory acidosis, and loss of consciousness. In a tension
pneumothorax, shifting of the mediastinum away from the site of the injury can obstruct the superior and inferior
vena cava resulting in reduced venous return. This in turn decreases cardiac preload and cardiac output.

Spontaneous pneumothorax has been reported in young people with a marfanoid habitus. The reason for this
association, while unknown, is hypothesized to be the presence of subtle abnormalities in connective tissue, though
not necessarily in elastin per se. Most spontaneous pneumothorax result from "blebs", expanded alveoli just under
the superficial surface of the lung, that rupture allowing the escape of air into the pleural cavity.

Pneumothorax can also occur as part of medical procedures, such as the insertion of a central venous catheter into
the subclavian vein. Other causes include mechanical ventilation, endotracheal intubation, laparoscopic surgery,
emphysema and less commonly other lung diseases bacterial or viral (pneumonia), metastatic tumors especially
sarcomas, lymphangioleiomyomatosis, eosinophilic granuloma, cystic fibrosis, alpha1-antitrypsin deficiency,
spontaneous or traumatic esophageal rupture, Pneumocystis carinii pneumonia, lung abscess, and asthma[1].
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.
Mechanics of a sucking chest wound. A. Air enters the chest through the opening in the chest wall during inspiration
(a). The lung collapses on the affected side (b), air passes out of affected bronchus. Air enters the bronchus from the
collapsed lung (c) and passes to the intact lung. The mediastinum shifts toward the uninvolved side (d), and
hemothorax occurs (e). B. During expiration, air escapes through the wound (a). The collapsed lung expands (b). Air
passes from the uninvolved side to the lung on involved side and out the trachea (c). The mediastinum shifts to the
involved side (d), and hemothorax occurs (e).

The lungs are located inside the chest cavity, which is a hollow space. Air is drawn into the lungs by the diaphragm
(a powerful abdominal muscle). The pleural cavity is the region between the chest wall and the lungs. If air enters
the pleural cavity, either from the outside (open pneumothorax) or from the lung (closed pneumothorax), the lung
collapses and it becomes mechanically impossible for the injured person to breathe, even with an open airway. If a
piece of tissue forms a one-way valve that allows air to enter the pleural cavity from the lung but not to escape,
overpressure can build up with every breath; this is known as tension pneumothorax. It may lead to severe shortness
of breath as well as circulatory collapse, both life-threatening conditions. This condition requires urgent
intervention.

Diagnosis

The absence of audible breath sounds through a stethoscope can indicate that the lung is not unfolded in the pleural
cavity. This accompanied by hyperresonance (higher pitched sounds than normal) to percussion of the chest wall is
suggestive of the diagnosis. The "coin test" may be positive. Two coins when tapped on the affected side, produce a
tinkling resonant sound which is audible on auscultation.[6]

If the signs and symptoms are doubtful, an X-ray of the chest can be performed, but in severe hypoxia, or evidence
of tension pneumothorax emergency treatment has to be administered first. An x-ray can illustrate the collapse of the
lung as extra black space, indicating the presence of air, will be seen in the x-ray around the lung. The lung shrivels
up away from the affected side and the mediastinum (trachea and other components) will shift towards the
unaffected side.[7]

In a supine chest X-ray the deep sulcus sign is diagnostic[8], which is characterized by a low lateral costophrenic
angle on the affected side.[9] In layperson's terms, the place where rib and diaphragm meet appears lower on an X-
ray with a deep sulcus sign and suggests the diagnosis of pneumothorax.
In Neonates the use of a transilluminator to suspected area will help visualize the air as radiating rings from light
source out.

More recently, ultrasound has been shown to be more sensitive than anteroposterior x-ray for detection of
pneumothorax. This is important in the initial evaluation of these patients, when the posteroanterior and lateral x-ray
studies may not be obtainable due to the patient's clinical condition.[10]

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 a recent Japanese report of 55,291 acupuncture treatments, an
approximate 1 incidence of 1 pneumothorax in 5000 cases was documented.

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.1
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 a recent 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.2
 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.
CT scan of the chest showing a pneumothorax on the patient's left side (right side on the image). A chest tube is in
place (small black mark on the right side of the image), the air-filled pleural cavity (black) and ribs (white) can be
seen. The heart can be seen in the center.

It most commonly arises:

 Spontaneously (more commonly in tall slim young males and in Marfan syndrome)
 Following a penetrating chest wound
 Following barotrauma to the lungs[2][3]

It may also be due to:

 Chronic lung pathologies including emphysema, asthma

 Acute infections
 Chronic infections, such as tuberculosis
 Lung damage caused by cystic fibrosis
 Lung Cancer
 Rare diseases that are unique to women such as Catamenial pneumothorax (due to endometriosis in the
chest cavity) and lymphangioleiomyomatosis (LAM).

Pneumothoraces are divided into tension and non-tension pneumathoraces. A tension pneumothorax is a medical
emergency as air accumulates in the pleural space with each breath. The increase in intrathoracic pressure results in
massive shifts of the mediastinum away from the affected lung compressing intrathoracic vessels. A non-tension
pneumothorax by contrast is of lesser concern because there is no ongoing accumulation of air and hence no
increasing pressure on the organs within the chest.

The accumulation of blood in the thoracic cavity (hemothorax) exacerbates the problem, creating a
hemopneumothorax.

[edit] Spontaneous pneumothorax

Spontaneous Pneumothorax can be classified as primary spontaneous pneumothorax and secondary spontaneous
pneumothorax. In primary spontaneous pneumothorax, it is usually characterized by a rupture of a bleb in the lung
while secondary spontaneous pneumothorax mostly occurs due to chronic obstructive pulmonary disease (COPD).

Primary

A primary spontaneous pneumothorax may occur without either trauma to the chest or any kind of blast injury. This
type of pneumothorax is caused when a bleb (an imperfection in the lining of the lung) bursts causing the lung to
deflate. The lung is reinflated by the surgical insertion of a chest tube. A minority of patients will suffer a second
instance. In this case, thoracic surgeons often recommend thorascopic pleurodesis to improve the contact between
the lung and the pleura. If multiple and/or bilateral occurrences continue, surgeons may opt for a far more invasive
bullectomy and pleurectomy to permanently adhere the lung to the interior of the rib cage with scar tissue, making
collapse of that lung physically impossible. Primary spontaneous pneumothorax is most common in tall, thin men
between 17 and 40 years of age, without any history of lung disease. Though less common, it also occurs in women,
usually of the same age and body type. The tendency for primary spontaneous pneumothorax sufferers to be tall and
thin is not due to weight, diet or lifestyle, but because the genetic predisposition toward those traits often coincides
with a genetic predisposition toward high volume lungs with large, burstable blebs. A small portion of primary
spontaneous pneumothoraxes occur in persons outside the typical range of age and body type.

Secondary

In secondary spontaneous pneumothorax, a known lung disease is the cause of the collapse [4]. The most common
cause is chronic obstructive pulmonary disease (COPD) with emphysematous bullae. However, there are several
other diseases that may also lead to spontaneous pneumothorax:

 Tuberculosis
 Pneumonia
 Asthma
 Cystic fibrosis
 Lung cancer
 Interstitial lung disease
 Marfan syndrome
 Lymphangioleiomyomatosis (LAM)[5]

[edit] Differential diagnosis

When presented with this clinical picture, other possible causes include:

 Acute Myocardial Infarction: presents with shortness of breath and chest pain, though MI chest pain is
characteristically crushing, central and radiating to the jaw, left arm or stomach. Whilst not a lung
condition, patients having an MI often happen to also have lung disease.
 Emphysema: here, delicate functional lung tissue is lost and replaced with air spaces, giving shortness of
breath, and decreased air entry and increased resonance on examination. However, it is usually a chronic
condition, and signs are diffuse (not localised as in pneumothorax).

Careful history taking and examination and a chest X-ray will allow accurate diagnosis.

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 the
following:
o Hypoxia
o 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.3
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.4
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.

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.5 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. 
o 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.
o 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.6 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.