From the Guidelines
The immediate recommendation for a patient with a suspected tension pneumothorax that persists despite having a chest tube inserted is to check the chest tube drainage system and ensure it is placed below the chest tube to verify proper function and patency, as recommended by guidelines for managing pneumothorax 1. This step is crucial because tension pneumothorax can lead to severe morbidity and mortality if not promptly addressed. The clinical signs of tension pneumothorax include severe respiratory distress, hypotension, tracheal deviation away from the affected side, absent breath sounds, and distended neck veins.
- Key considerations in managing tension pneumothorax include:
- Ensuring the chest tube is properly placed and functioning
- Checking for any kinks or clots that may obstruct the tube
- Considering the insertion of an additional chest tube if the first one is inadequate
- Providing high concentration oxygen to the patient
- The development of tension pneumothorax is often heralded by a sudden deterioration in the cardiopulmonary status of the patient, and it should be particularly suspected in those on mechanical ventilators or nasal non-invasive ventilation who suddenly deteriorate or develop cardiac arrest, as noted in guidelines for managing spontaneous pneumothorax 1.
- The use of suction in chest tube management is also an important consideration, with recommendations suggesting that suction should not be applied directly after tube insertion but can be added after 48 hours for persistent air leak or failure of a pneumothorax to re-expand, using high volume, low pressure suction systems 1.
From the Research
Immediate Recommendations for Tension Pneumothorax
The patient's situation involves a suspected tension pneumothorax that persists despite the insertion of a chest tube. The immediate steps to address this issue are critical for the patient's survival and recovery.
- Checking the Chest Tube Drainage System: The first and most immediate action should be to ensure that the chest tube drainage system is functioning correctly. This involves checking that the tube is not kinked, blocked, or malpositioned and that the drainage system is placed below the level of the chest tube to facilitate gravity-assisted drainage 2.
- Ensuring Proper Placement and Function: If the chest tube is not draining properly, it may be necessary to check its placement and ensure that it is in the correct position within the pleural space. However, advancing the present chest tube or inserting a second chest tube may be considered based on clinical judgment and the patient's response to initial treatment.
Considerations for Patient Management
- Paralyzing the Patient: While paralyzing the patient might be considered to manage certain aspects of ventilatory support, it is not directly related to the management of a tension pneumothorax unless the patient's movements are interfering with the chest tube's function or the ventilator's effectiveness.
- Insertion of a Second Chest Tube: The decision to insert a second chest tube should be based on the clinical assessment of the patient's condition, including the size of the pneumothorax, the patient's respiratory and hemodynamic status, and the effectiveness of the initial chest tube in resolving the pneumothorax.
Clinical Evidence and Guidelines
Studies on the management of pneumothorax, including tension pneumothorax, emphasize the importance of early and effective drainage of the pleural space to restore lung expansion and improve respiratory function 3, 4, 5. The choice of management strategy may depend on the underlying cause of the pneumothorax, the size of the pneumothorax, and the patient's clinical condition. Recent literature supports the use of less invasive management strategies for pneumothorax, including the use of smaller chest tubes or pigtail catheters, and conservative management for small or occult pneumothoraces 4, 2.