What is the recommended treatment for tension pneumothorax?

Treatment of Tension Pneumothorax

Immediate needle decompression is required for tension pneumothorax, using a 14-gauge needle/angiocatheter with a minimum length of 7 cm (ideally 8.25 cm) at the 2nd intercostal space in the midclavicular line, followed by tube thoracostomy. 1

Diagnosis

Tension pneumothorax is a life-threatening emergency characterized by:

• Progressive dyspnea/respiratory distress
• Attenuated or absent breath sounds on the affected side
• Tachycardia, hypotension, and shock in severe cases 1
• Portable ultrasound can aid diagnosis with 92.0% sensitivity and 99.4% specificity 1

Important note: Tracheal deviation is not a reliable sign and intervention should not be delayed until this sign appears 1.

Emergency Management Algorithm

Step 1: Immediate Needle Decompression

• Site selection:

  • Primary: 2nd intercostal space in the midclavicular line (2nd ICS-MCL) 1
  • Alternative: 5th intercostal space in the midaxillary line (5th ICS-MAL), particularly for right-sided pneumothoraces 1

• Needle selection:

  • Use a 14-gauge angiocatheter
  • Minimum length of 7 cm, ideally 8.25 cm 1, 2
  • Shorter needles have high failure rates (39-76%) 3

• Technique:

  • Insert needle perpendicular to chest wall, just above the rib
  • Advance until a rush of air is heard/felt (indicates entry into pleural space)
  • Attach a one-way valve to the catheter if available 1
  • Leave catheter in place until definitive chest tube can be inserted 1

Step 2: Definitive Management

• Proceed to tube thoracostomy (chest tube placement) 1
• This provides definitive treatment following needle decompression

Site Selection Considerations

• Left-sided pneumothorax: Use 2nd ICS-MCL due to lower risk of cardiac injury 1
• Right-sided pneumothorax: Either 2nd ICS-MCL or 5th ICS-MAL can be used 1
• The internal mammary artery is typically located approximately 5.5-5.7 cm medial to the intended puncture site at the 2nd ICS-MCL, providing adequate safety margin 2

Common Pitfalls and Complications

1. Insufficient needle length: Studies show chest wall thickness averages 3.5 cm in men and can be greater in women, with up to 35.4% of women having chest walls thicker than 4.5 cm 4, 2

2. Catheter dislodgment: A common cause of procedure failure, particularly at the 2nd ICS 1

3. Iatrogenic injury: Risk of damage to underlying structures with improper placement 1

4. Unnecessary decompression: Performing the procedure when tension pneumothorax is not present 1

5. Failure to recognize progression: An undetected small pneumothorax can progress to tension pneumothorax during positive pressure ventilation 5

Monitoring After Decompression

• Monitor closely for recurrence of tension pneumothorax symptoms 1
• Be prepared to repeat needle thoracostomy or proceed to tube thoracostomy if symptoms recur 1
• Chest tube can typically be removed after approximately one week following evaluation 5

Special Considerations

• Positive pressure ventilation can aggravate or convert a simple pneumothorax to a tension pneumothorax 5
• Anesthesiologists and emergency providers should remain vigilant for signs of tension pneumothorax development, even in patients with normal preoperative assessments 5