What is the management of tension pneumothorax?

Management of Tension Pneumothorax

Tension pneumothorax requires immediate needle decompression with a cannula of adequate length (at least 4.5 cm) in the second intercostal space mid-clavicular line, followed by chest tube insertion once the patient is stabilized. 1

Clinical Presentation and Recognition

Tension pneumothorax is a life-threatening emergency characterized by:

• Intrapleural pressure exceeding atmospheric pressure throughout the respiratory cycle
• One-way valve mechanism allowing air entry but preventing exit
• Rapid deterioration in cardiopulmonary status due to:
  • Impaired venous return
  • Reduced cardiac output
  • Hypoxemia

Clinical features include:

• Rapid labored respiration
• Cyanosis
• Sweating
• Tachycardia
• Hypotension (in advanced cases)
• Decreased or absent breath sounds on affected side
• Tracheal deviation away from affected side (late sign)

Important: The clinical presentation may not correlate with radiographic findings, and tension pneumothorax should be diagnosed clinically rather than waiting for imaging confirmation in unstable patients 1.

Emergency Management Algorithm

1. Immediate Actions

• Administer high-concentration oxygen
• Perform immediate needle decompression:
  • Location: Second intercostal space in mid-clavicular line
  • Equipment: Cannula of adequate length (at least 4.5 cm)
  • Technique: Insert perpendicular to chest wall to full hub depth
  • Hold in place for 5-10 seconds to allow complete decompression 2

2. Definitive Management

• Insert intercostal chest tube after initial decompression
• Leave the decompression cannula in place until chest tube is functioning properly
• Confirm proper chest tube function by observing bubbling in underwater seal system 1

3. Monitoring and Follow-up

• Monitor vital signs closely
• Obtain chest radiograph to confirm tube placement and lung re-expansion
• Provide adequate analgesia
• Consider respiratory specialist consultation if:
  • Underlying chronic lung disease exists
  • Re-expansion is not achieved
  • Persistent air leak occurs 1

Special Considerations

Cannula Selection

• Use a cannula at least 4.5 cm in length (critical)
• Studies show 57% of patients have chest wall thickness >3 cm
• Inadequate length is a common cause of decompression failure 1

Alternative Decompression Sites

• Primary: Second intercostal space at midclavicular line
• Alternative: Fifth intercostal space at anterior axillary line
• Both sites are acceptable, with no clear preference established 2

Ventilated Patients

• Tension pneumothorax develops more rapidly in mechanically ventilated patients
• Particularly suspect in patients who suddenly deteriorate on ventilation
• Requires even more urgent decompression than in spontaneously breathing patients 3

Spontaneously Breathing vs. Ventilated Patients

• Tension pneumothorax develops more rapidly and is more immediately life-threatening in ventilated patients
• In spontaneously breathing patients without hemodynamic instability, careful monitoring while preparing for chest tube insertion may be appropriate 4
• However, if clinical signs of tension are present, immediate decompression should not be delayed 1

Pitfalls to Avoid

1. Delayed recognition: Do not wait for radiographic confirmation in unstable patients with clinical signs of tension pneumothorax
2. Inadequate cannula length: Using cannulas <4.5 cm may fail to reach the pleural space
3. Removing decompression cannula too early: Leave in place until chest tube is functioning
4. Failing to recognize tension in ventilated patients: High index of suspicion needed for sudden deterioration on ventilation
5. Clamping chest tubes: This can lead to recurrent tension pneumothorax and should be avoided 1

Remember that tension pneumothorax is a clinical diagnosis requiring immediate intervention. While imaging can confirm the diagnosis in stable patients, treatment should not be delayed in patients with cardiorespiratory compromise.