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Background: A pneumothorax refers to a collection of gas in the pleural space resulting in collap

affected side. A tension pneumothorax is a life-threatening condition caused by air within the pleu
under pressure; displacing mediastinal structures and compromising cardiopulmonary function. A
pneumothorax results from blunt or penetrating injury that disrupts the parietal or visceral pleura.
injuries secondary to medical or surgical procedures.

Pathophysiology: A tension pneumothorax results from any lung parenchymal or bronchial injur
way valve and allows free air to move into an intact pleural space but prevents the free exit of tha
this mechanism, the positive pressure used with mechanical ventilation therapy can cause air trap

As pressure within the intrapleural space increases, the heart and mediastinal structures are push
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 contra
compromise effective gas exchange. This hypoxia and decreased venous return caused by comp
relatively thin walls of the atria impair cardiac function. The decrease in cardiac output results in h
ultimately, in hemodynamic collapse and death, if untreated.

Frequency:

In the US: A study conducted from 1959-1978 involving a US community with an average
reported an incidence of primary spontaneous pneumothorax of 7.4 per 100,000 persons p
1.2 per 100,000 persons per year for women. When these figures are extrapolated, about
develop primary spontaneous pneumothorax in the United States per year.

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


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


intensive care treatment modalities have become increasingly dependent on positive-press
central venous catheter placement, and other causes that potentially induce iatrogenic pne

Mortality/Morbidity: The clinician should assume that a tension pneumothorax results in hemod
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
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


frequently begins 1-3 days after menses onset. Its etiology may be primarily related to ass
diaphragmatic defects.

Age: Pneumothorax occurs in 1-2% of all neonates. The incidence of pneumothorax in infants wi
respiratory distress syndrome is higher. In one study, 19% of such patients developed a pneumot

CLINICAL Section 3 of
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History: The signs and symptoms produced by tension pneumothorax are usually more impressi
with a simple pneumothorax. They may include the following:

Chest pain (90%)

Dyspnea (80%)

Anxiety

Fatigue

Physical: Findings at physical examination may include the following:

Respiratory distress and/or arrest

Cyanosis

Unilaterally decreased or absent lung sounds

Lung sounds transmitted from the nonaffected hemithorax are minimal with auscultation at

Tachypnea

Hyperresonance of the chest wall on percussion

Increasing resistance to providing adequate ventilation assistance

Tachycardia

Tracheal deviation (relatively late finding due to midline shift with a tension pneumothorax)

Jugular venous distension (with a tension pneumothorax)

Hypotension (key sign of a tension pneumothorax)

Pulsus paradoxus

Mental status changes, including decreased alertness and/or consciousness

Abdominal distension (from increased pressure in the thoracic cavity producing caudal dev
diaphragm and from secondary pneumoperitoneum produced as air dissects across the di
pores of Kohn)

Causes: A wide variety of disease states and circumstances increase the patients risk of a pneu
pneumothorax is complicated by a one-way valve effect, tension pneumothorax may result.

Infants requiring ventilatory assistance and those with meconium aspiration have a particu
tension pneumothorax. Aspirated meconium may serve as a one-way valve and produce a
pneumothorax.

Trauma may cause a pneumothorax.

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

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


accidents, falls, and altercations involving laterally directed blows.

o Any penetrating wound that produces an abnormal passageway for gas exchange i
spaces and that results in air trapping may produce a tension pneumothorax.

o In a recent study, 12% of patients with asymptomatic chest stab wounds had a dela
hemothorax.

Many procedures performed in an intensive care or emergency setting can result in an iatr
pneumothorax and tension pneumothorax. Examples of these procedures include mechan
therapy, central venous cannulation; cardiopulmonary resuscitation; hyperbaric oxygen the
transbronchial, or transthoracic lung biopsy; liver biopsy or surgery; and neck surgery.

Pneumothorax is associated with asthma, chronic obstructive pulmonary disease, pneumo


Staphylococcus, Klebsiella, Pseudomonas, and Pneumocystis species), pertussis, tubercu
and cystic fibrosis.

o In pulmonary disorders such as asthma and emphysema, hyperexpansion disrupts

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


plug may play a role.

Marfan syndrome is associated with an increased risk of pneumothorax.

Individuals may inherit a predisposition for primary spontaneous pneumothorax.

DIFFERENTIALS Section 4 of

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Acute Coronary Syndrome


Anxiety
Asthma
Congestive Heart Failure and Pulmonary Edema
Diaphragmatic Injuries
Dissection, Aortic
Esophageal Perforation, Rupture and Tears
Foreign Bodies, Trachea
Myocardial Infarction
Pediatrics, Pertussis
Pediatrics, Pneumonia
Pericarditis and Cardiac Tamponade
Pneumonia, Aspiration
Pneumonia, Bacterial
Pneumonia, Empyema and Abscess
Pneumonia, Immunocompromised
Pneumonia, Mycoplasma
Pneumonia, Viral
Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum
Respiratory Distress Syndrome, Adult
Tuberculosis

Other Problems to be Considered:

Airway obstruction
Hemothorax

WORKUP
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Lab Studies:

ABG analysis does not replace physical diagnosis nor should treatment be delayed while a
pneumothorax is suspected. However, ABG analysis may be useful in evaluating the follow

o Hypoxia

o Hypercarbia and respiratory acidosis

Imaging Studies:

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

Chest radiography

o Although the initial chest radiograph may show no evidence of pneumothorax, cons
pneumothorax development in any penetrating chest wound. Obtain serial chest rad
injury to rule this out. Some authors advocate the acquisition of only one or two seri

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

o When evaluating the chest radiograph for pneumothorax, assess rotation. Rotation
also mimic a mediastinal shift.

o In evaluating the radiograph for rotation, compare the symmetry and shape of the cl
the ribs in the middle lung fields on each side on the anteroposterior or posteroante
ribs on each side often have unequal lengths.

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


apices of an upright chest radiograph, and scrutinize the costophrenic and cardioph

o A skin fold can be mistaken for a pneumothorax. Unlike pneumothoraces, skin folds
and lung markings can be seen peripheral to the skin fold line. Viewing the film unde
discern obscure peripheral lung markings.

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


of pneumothorax on the radiograph, a 2.5-cm margin of gas peripheral to the collap
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

o A CT scan is more sensitive than a chest radiograph in the evaluation of small pneu
although the clinical significance of these occult pneumothoraces is unclear, particu

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

Procedures:

Needle thoracostomy is performed as follows:

o Locate puncture site. The second intercostal space in the midclavicular line on the a
is most commonly recommended site.

o Prepare the puncture site with Betadine and/or alcohol scrubs.

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


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 pneumothora
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.

Tube thoracostomy is performed as follows:

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


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 Be
site with lidocaine.

o Make a 3-4-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 imm
damage to the underlying lung. Then, slide a finger over the clamp to maintain the f

o Perform a digital examination to assess the location and to evaluate pulmonary adh
and feel for the diaphragm and possible intra-abdominal structures. To avoid losing
until 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 be

o Attach the tube to a water seal and vacuum device (eg, Pleur-Evac). Look for respir
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
Cover the site with Vaseline-impregnated gauze, and apply a suitable dressing.

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

TREATMENT
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Prehospital Care: Attention to the ABCs is mandatory for all patients with thoracic trauma. Evalu
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
pneumothorax and to promptly perform needle decompression in the prehospital setting lik
cardiac arrest.

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


unnecessary invasive procedures. Close cooperation and accurate communication betwee
service personnel is of paramount importance.

To prevent reentry of air into the pleural cavity after needle thoracostomy and decompress
valve should be attached to the distal end of the Angiocath. If available, a Heimlich valve m
valve is not available, attach a finger condom or the finger of a rubber glove with its tip rem
valve device.

Clothing covering a wound that communicates with the chest cavity can play a role in prod
enter the pleural cavity but hindering its exit. Removing such clothing items from the wound
pneumothorax.

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

Emergency Department Care: For all patients with thoracic injury, immediate and careful attenti
patency of the airway and adequacy of the ventilatory effort. Carefully evaluate the cardiovascula
and a pericardial tamponade can cause similar findings.

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


compromise, hemodynamic instability, or clinical deterioration. Place large-bore catheters,
with pneumothorax, and the patient may, therefore, require immediate intravenous infusion

Immediately perform needle thoracostomy or chest tube placement if the clinical condition
thoracostomy has been performed, chest tube insertion must follow.

If a hemothorax is associated with the pneumothorax, additional chest tubes may be need
the hemopneumothorax requires insertion of a second chest tube, the second tube should
posterior to the diaphragm.

Chest tubes are attached to a vacuum apparatus that continual removes air from the pleur
and heals, thereby preventing continued air leakage. After air leaks have ceased for 24 ho
chest tube removed.

The process of lung re-expansion and healing is not immediate and may be complicated b
therefore, usually left in place for at least 3 days unless the clinical condition warrants a lon

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

o A subset of patients who have a small (<15-20%), minimally symptomatic pneumoth


and monitored by using serial chest radiographs.

o In these patients, administration of 100% oxygen promotes resolution by speeding t


into the pulmonary vasculature.

Consultations:

Treatment of tension pneumothorax should commence immediately after diagnosis, withou


evaluation.

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

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MEDICATION
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A tension pneumothorax requires treatment with procedural modalities. Anesthetics and analgesic
distress. Medication may be necessary to treat the pulmonary disorder that caused the pneumoth
are included in the treatment of a pneumothorax that developed as a sequela of staphylococcal p
administration of prophylactic antibiotics after chest tube insertion may reduce the incidence of co

FOLLOW-UP
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Further Inpatient Care:

If the patient has had repeated episodes of pneumothorax or if the lung remains unexpand
surgery may be necessary. The surgeon may use treatment options such as thoracoscopy
of blebs or pleura, or open thoracotomy.

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

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 ins
simple pneumothorax that requires positive pressure ventilation.

When subclavian vein cannulation is required, use the supraclavicular approach rather tha
possible to help decrease the likelihood of pneumothorax formation.

Prompt recognition and treatment of bronchopulmonary infections decreases the risk of pr

Complications:

Respiratory distress and/or arrest

Cardiac arrest

Pulmonary edema (following lung re-expansion)

Empyema

Persistent bronchopulmonary fistula

Pneumomediastinum

Pneumopericardium

Pneumoperitoneum

Pyopneumothorax

Hemopneumothorax

Prognosis:

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

MISCELLANEOUS
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Medical/Legal Pitfalls:

The diagnosis of a tension pneumothorax should be made based on the history and physic
or CT scan should be used only in those instances when the clinician is in doubt regarding
clinical condition is sufficiently stable. Obtaining such imaging studies when the diagnosis
causes an unnecessary and potentially lethal delay in treatment.

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


insertion). However, the clinician should be wary of prematurely diagnosing a tension pneu
hypotension, or cardiopulmonary compromise. If the patient's clinical presentation is quest
the clinician should re-examine the patient and request immediate portable chest radiograp
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 pe
trauma and mental status changes, hypoxia, and acidosis, symptoms may be attributed to
a tension pneumothorax. Portable chest radiography should always be included in the initia

When assessing the trauma patient, be aware that clinical presentations of tension pneum
tamponade may be similar.

Maintain a high index of suspicion for a tension pneumothorax in patients using ventilators
instability or cardiac arrest, particularly if they require increasing peak inspiratory pressures
pneumothorax and/or tension pneumothorax include those with COPD who are using vent
syndrome; and those requiring a tidal volume greater than 12 mL/kg, a peak airway pressu
end-expiratory pressure greater than 15 cm H2O.

Avoid assuming that a patient with a chest tube does not have a tension pneumothorax if h
instability. Chest tubes can become plugged or malpositioned and cease to function. Also,
the chest tube may produce tension pneumothorax.

PICTURES
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Caption: Picture 1. Pneumothorax, Tension and Traumatic.

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Caption: Picture 2. Pneumothorax, Tension and Traumatic.

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Caption: Picture 3. Pneumothorax, Tension and Traumatic.
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Caption: Picture 4. Pneumothorax, Tension and Traumatic.

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Caption: Picture 5. Pneumothorax, Tension and Traumatic.

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Caption: Picture 6. Pneumothorax, Tension and Traumatic.

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BIBLIOGRAPHY
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Bense L, Eklund G, Wiman LG: Smoking and the increased risk of contracting spontaneou
1009-12[Medline].
Ludwig J, Kienzle GD: Pneumothorax in a large autopsy population. A study of 77 cases. A
6[Medline].
Melton LJ, Hepper NG, Offord KP: Incidence of spontaneous pneumothorax in Olmstead C
Respir Dis 1979; 120: 1379[Medline].
Ogata ES, Gregory GA, Kitterman JA: Pneumothorax in the respiratory distress syndrome:
gases, and pH. Pediatrics 1976; 58: 117-183[Medline].

Wilder RJ, Beacham EG, Ravitch MM: Spontaneous pneumothorax complicating pulmona
1962; 46: 331.