tension pneumothorax

Etiology

• trauma (blunt or penetrating)
• barotrauma (auto-PEEP)
• central venous catheter placement
  • subclavian catheter
  • internal jugular catheter
• conversion of simple pneumothorax to tension pneumothorax
• chest compressions during cardiopulmonary resuscitation
• pneumoperitoneum
• fiberoptic bronchoscopy with closed-lung biopsy
• markedly displaced thoracic spine fractures
• acupuncture has been reported to result in pneumothorax.6,7,8
• colonoscopy & gastroscopy (case reports)
• percutaneous tracheostomy

Pathology

• pleural air under positive pressure
• impaired venous return to the heart
  • compression of the inferior vena cava
  • decreased venous return to the heart
  • decreased diastolic filling
  • decreased cardiac output
  • obstructive shock

Clinical manifestations

• agitation
• progressive hypoxia
• hypotension
• tachycardia
• for patients on mechanical ventilation, especially with PEEP, elevation of plateau airway pressure with similar elevation in peak airway pressure concurrent with a decrease in tidal volume, strongly suggests tension pneumothorax
• lack of breath sound on affected side (unilateral)
• tracheal deviation

Diagnostic procedures

• pulse oxymetry may show falling SaO2
• electrocardiogram:
  • electromechanical dissociation may occur

Radiology

• point-of-care chest ultrasonography
  • confirm diagnosis (prior to needle thoracostomy)
  • benefit to risk of delay for ultrasound favorable
• diagnosis can be confirmed by chest radiograph
  • do not wait for chest X-ray unless diagnosis uncertain

Complications

• hemodynamic compromise (cardiogenic shock) may occur

Management

• immediate therapeutic intervention is indicated
  • administer oxygen (high concentration)
  • needle decompression
    • 2nd intercostal space, over 3rd rib (arteries, veins, nerve run under rib)
  • tube thoracostomy
• patients on mechanical ventilation: minimize airway pressure

More general terms

• pneumothorax