Tension pneumothorax
Theory
This is an emergency situation requiring immediate assessment and management.
Management focuses on urgent chest decompression with wide bore needle followed by a chest tube.
It occurs when air leaks from a pulmonary laceration or tear into the pleural cavity, but is sealed in the space by the parietal pleura. The rising tension collapses the affected lung and displaces the mediastinal structures to the other side. This causes:
- Respiratory compromise from lung collapse.
- Kinking of the IVC by mediastinal displacement reducing venous return, preload, and cardiac output leading to cardiopulmonary arrest.
Immediate intern management
Attend patient and make rapid assessment.
If patient unconscious/arrest
- Tell nursing staff to call Code Blue then move to end of bed.
- Perform triple manoeuvre – chin lift, jaw thrust, head tilt.
- Clear mouth – suction secretions.
- Insert Guedel airway and bag and mask.
- Check pulse and if arrested start CPR.
If conscious/severe respiratory distress
Call code blue
Assess patient – oxygen saturations, PR, BP
- Tracheal deviation
- Reduced chest movement
- Hyperresonance to percussion } = tension pneumothorax
- Decreased breath sounds
Tension pneumothorax (TP)
- Needle pleurocentesis
- Insert wide bore IV needle into second IC space in mid-clavicular line.
- The tension will be relieved instantly but the patient needs an urgent chest tube.
- Oxygen by mask.
- Notify surgical registrar/ICU registrar urgently regarding need for chest tube.
- Organise chest tube and chest tube tray as a matter of priority with nursing/medical staff (but do not leave patient unless help has arrived).
- If patient deteriorates again (saturations begin to fall) then insert second IV needle into second IC space.
- Insert chest tube and place on 10 cm continuous underwater suction.
- Obtain post insertion CXR.
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Causes
- Often spontaneous (rupture subpleural bullae)
- Asthma/COAD
- Ventilated patients
- Trauma
- Pleura entered during attempted placement of CVC line
- Carcinoma lung
- Pneumonia, TB, lung abscess, CF
- Connective tissue disorder
Clinical features (obtain rapidly)
History
- Basic information about patient
- Sudden onset sharp pleuritic chest pain with SOB
Examination
- Pt in extremis
- Respiratory distress
- Trachea deviated away from side of TP
- Reduced chest expansion on side of TP
- Hyper-resonant to percussion
- Absent breath sounds on side of TP
- Displaced apex beat
Insertion of chest tube
- Local anaesthetic. Sterile technique
- Incision fifth IC space ant. Axillary line or second IC space mid-clavicular line
- Enter ‘above the rib below’
- Dissect down to muscles
- Split muscles using artery forceps
- Blunt dissect through to parietal pleura (air rush)
- Remove trocar from chest tube. Never use the trocar
- Insert chest tube with long artery forceps directing upwards
- Connect to underwater suction system with 10 cm continuous suction. Check CXR for position
Investigations
(Do not wait for these tests before insertion of test tube)
- Basic/CXR blood tests
- ABG
Further management
- Insertion of a chest tube as described above
- Continued air leak through pneumothorax may require thoracoscopy/thoracotomy
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