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Updated: Dec 22 2021

Tension Pneumothorax

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  • Snapshot
    • A 56-year-old male with a history of chronic obstructive pulmonary disease presents with pleuritic chest pain and trouble breathing. Vital signs are significant for a blood pressure of 88/54 mmHg and a pulse of 115/min. On exam, there is jugular venous distension, decreased breath sounds on the right side, with wheezes. A chest radiograph is obtained.
  • Introduction
    • Tension pneumothorax results from positive pressure build-up secondary to a flap valve mechanism (or one-way valve) resulting in total lung collapse
      • tracheal shifting to opposite end
      • expansion of chest wall
    • Increased intrathoracic pressure restricts cardiac output
      • may result in shock and death
    • Etiologies include
      • penetrating and blunt chest trauma
      • infection
      • positive-pressure mechanical ventilation
      • iatrogenic
        • placement of central venous line
        • epidural thoracic catheter placement
  • Presentation
    • Symptoms
      • acute-onset, unilateral, pleuritic chest pain
      • dyspnea/acute respiratory distress
      • syncope
    • Physical exam
      • tachypnea and tachycardia
      • unilateral decreased or absent breath sounds
      • hyperresonance
      • decreased or absent tactile fremitus
      • falling O2 saturation
      • deviated trachea
      • JVD
      • hypotension
      • subcutaneous emphysema
    • Ultrasound
      • fast with no radiation exposure
      • requires a bedside ultrasound readily available
      • guidance for tube placement
    • Chest radiography (CXR)
      • do not obtain CXR if tension pneumothorax is suspected - immediately decompress the pleural space
      • best observed in end-expiratory films
        • shows unilateral absence lung parenchyma
        • and contralateral mediastinal shift
  • Differential
    • Primary spontaneous pneumothorax, secondary pneumothorax, acute asthma, inhalation of foreign object, myocardial infarction, ruptured aortic aneurysm
    • Tracheobronchial rupture
      • if a recurrent pneumothorax that recurs after chest tube placement
  • Treatment/Management
    • Prevention
      • no preventive measures can be taken for initial insult
      • chest tube placement following needle decompression prevents recurrence
    • Non-operative
      • do not resolve spontaneously
        • unlike small, simple pneumothoraces
      • supplemental O2 therapy
        • following operative intervention may be required
    • Operative
      • immediate needle decompression
        • second intercostal space at the midclavicular line with 14 or 16-gauge needle
      • followed by chest tube placement
  • Complications
    • Shock and death if left untreated
  • Prognosis
    • Shock and death will result if not immediately recognized and treated
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