From the Guidelines
Tension pneumothorax is a life-threatening emergency that requires immediate decompression with a cannula of adequate length inserted into the second intercostal space in the midclavicular line, as recommended by the BTS guidelines 1.
Diagnosis
The diagnosis of tension pneumothorax is primarily clinical, based on the patient's symptoms and physical examination findings, which include:
- Severe respiratory distress
- Rapid laboured respiration
- Cyanosis
- Sweating
- Tachycardia
- Tracheal deviation away from the affected side
- Absent breath sounds on the affected side
- Hyperresonance to percussion
- Distended neck veins It is essential to suspect tension pneumothorax in patients who suddenly deteriorate or develop cardiac arrest, especially those on mechanical ventilators or nasal non-invasive ventilation.
Treatment
The treatment of tension pneumothorax involves:
- Immediate needle decompression using a cannula of adequate length (at least 4.5 cm) inserted into the second intercostal space in the midclavicular line, as recommended by the BTS guidelines 1
- Administration of high concentration oxygen
- Removal of air from the pleural space until the patient is no longer compromised
- Insertion of an intercostal tube into the pleural space for definitive management
- Monitoring of vital signs and arrangement for definitive chest tube placement It is crucial to note that the development of tension pneumothorax is not dependent on the size of the pneumothorax, and the clinical scenario may correlate poorly with chest radiographic findings. Therefore, treatment should not be delayed for radiographic confirmation, especially in critically ill patients.
From the Research
Diagnosis of Tension Pneumothorax
- Tension pneumothorax is a severe chest complication of blunt or penetrating trauma, characterized by the confinement of respired gases within the pleural cavity at increasing pressure, resulting in hemodynamic collapse 2
- Diagnosis can be made using chest X-ray, but computed tomography (CT) scan of the chest remains the gold standard for diagnosis 3
- Thoracic ultrasound has also been emerging as a diagnostic tool, proven to be superior to chest X-ray in making a diagnosis 3
Treatment of Tension Pneumothorax
- Immediate decompression is the lifesaving action in patients with tension pneumothorax, typically performed using needle thoracostomy 4, 2
- Needle decompression should be followed by tube thoracostomy, with a small-bore chest tube recommended as the first line management of pneumothorax 3
- The procedure should be performed in adherence to universal guidelines, with consideration of the optimal needle length and site to improve effectiveness and minimize complications 5, 6
- A catheter length of at least 7 cm is recommended, inserted perpendicular to the horizontal plane at the midhemithoracic line (MHL) site, which is considered the safest site 6