Tension Pneumothorax - Quick Consult
Last Updated / Reviewed: June 2022

Definition
Key History
Key Physical Exam
Risk Factors for Tension Pneumothorax
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment
Complications

Definition

Inspired air accumulates into pleural space (between the lung and chest wall) with no means of escape. A type of one-way valve mechanism develops. More air increases lung compression and causes hypoxia/hemodynamic compromise. Represents a life-threatening emergency.

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Key History

  • Blunt or penetrating trauma
  • Chest pain
  • Dyspnea
  • Injury to trachea, bronchia, lungs or sucking chest wound
  • Intubated patient
  • Tachypnea
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Key Physical Exam

  • Cyanosis
  • Diminished or absent breath sounds on affected side
  • Hypotension
  • JVD – may or may not be present
  • Neck or chest crepitus
  • Respiratory distress
  • Tachycardia
  • Tachypnea
  • Tracheal shift- deviation to contralateral side
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Risk Factors for Tension Pneumothorax

  • Penetrating or blunt trauma
  • Barotrauma
  • Central venous catheter placement
  • CPR
  • Displaced spinal fracture
  • Iatrogenic
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Differential Diagnosis

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Diagnostic Testing

Text / literature information and recommendations include:

  • None – If suspect diagnosis of tension pneumothorax, treat immediately—do not wait for CXR.
  • Chest x-ray:
    • Radiographic Features – The main radiologic feature of a pneumothorax is a white visceral pleural line, which is either straight or convex towards the chest wall, separated from the parietal pleura by an avascular collection of gas. No pulmonary vessels are visible beyond the visceral pleural edge.
    • Upright Chest Radiographs – In upright patients, the accumulation of gas occurs primarily in an apicolateral location. As little as 50 mL of pleural gas can be visible. A lateral width of 1 cm corresponds to about a 10 percent pneumothorax. The size of a pneumothorax is accounted for by the collapsed lung and, to a greater degree, by the expanding chest cage. Despite a considerable loss of volume, the collapsed lung preserves its transradiancy because of hypoxic vasoconstriction that diminishes its blood flow.
    • Inspiratory Films – Recommended as the initial examination of choice for pneumothorax detection.
    • Lateral Decubitus View – A small pneumothorax can be more easily detected in the lateral decubitus view. In this position, as little as 5 mL of pleural gas is visible on the non-dependent side.
    • Tension Pneumothorax – Tension pneumothorax shows a distinct shift of the mediastinum to the contralateral side and flattening or inversion of the ipsilateral hemidiaphragm.
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Clinical Risk and Safety Pearls

  • If tension pneumothorax is suspected treat immediately - do not wait for CXR.
  • Tube thoracostomy is a life-saving intervention delayed while waiting for x-ray results.
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Treatment

Common text / literature recommendations include:
  • 100% oxygen
  • Immediate needle decompression - do not wait for CXR
    • Insert a large bore IV catheter (14-16 gauge best, 18 gauge OK) into 2nd intercostal space, midclavicular line (1-2 cm from sternal edge), just superior to the third rib. Leave plastic sheath on needle; more than one needle may need to be placed. If tension pneumo present, a rush of air will likely be heard through the needle – this is diagnostic as well as therapeutic. Must have chest tube placement after this procedure regardless of whether rush of air present or not.
  • After immediate needle decompression, place chest tube
  • CXR
  • Acute surgery consult
  • Monitor vital signs
  • Admit all patients
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Complications

  • Hemothorax after needle decompression
  • Intercostal neurovascular bundle injury from thoracostomy tube placement
  • Misdiagnosis of a pneumothorax as a tension pneumothorax, thereby, converting a pneumothorax into an open pneumothorax
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  1. Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think?. Emerg Med J. Jan 2005;22(1):8-16.
  2. Nicks B, Manthey D. Pneumothorax. In: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016.
  3. Rawlins R, Brown KM, Carr CS, Cameron CR. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J. Jul 2003;20(4):383-4.
  4. Roberts DJ, Leigh-Smith S, Faris PD, et al. Clinical presentation of patients with tension pneumothorax: A systematic review. Ann Surg. 2015;261(6):1068-1078.
  5. Schuurmans MM, Davel S, Diacon AH. Non-responding ''tension pneumothorax'' following stab wounds. Respiration. Jan-Feb 2003;70(1):100.
  6. Staub LJ, Biscaro RRM, Kaszubowski E, Maurici R. Chest ultrasonography for the emergency diagnosis of traumatic pneumothorax and haemothorax: A systematic review and meta-analysis. Injury. 2018;49(3):457-466.

This is intended solely as reference material and is not a recommendation for any specific patient. The practitioner must rely upon his or her own professional judgment and medical decision-making to determine whether it is relevant in a particular case. Materials are derived from medical and nursing texts, medical literature and national guidelines and should not be considered complete or authoritative. Users must rely on specific patient presentation, experience and judgment when utilizing any of the information contained herein relative to an actual patient.
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