Tension Pneumothorax Management: Step by Step
Tension pneumothorax requires immediate needle decompression with a cannula of adequate length (at least 4.5 cm) inserted into the second intercostal space in the mid-clavicular line, followed by chest tube placement. 1
Recognition of Tension Pneumothorax
- Tension pneumothorax occurs when intrapleural pressure exceeds atmospheric pressure throughout the respiratory cycle, creating a one-way valve effect that draws air into the pleural space during inspiration but prevents its escape during expiration 1
- Clinical presentation includes:
- Rapid, labored respiration
- Cyanosis
- Sweating
- Tachycardia
- Progressive respiratory distress
- Hypoxemia
- Impaired venous return and reduced cardiac output 1
- Particularly suspect tension pneumothorax in patients on mechanical ventilation or non-invasive ventilation who suddenly deteriorate or develop pulseless electrical activity (PEA) 1, 2
- Note that clinical severity may not correlate with radiographic findings - tension pneumothorax is a clinical diagnosis requiring immediate intervention 1
Step-by-Step Management
Step 1: Initial Assessment and Oxygen Administration
- Immediately administer high-concentration oxygen 1
- Rapidly assess for signs of cardiorespiratory collapse 1
Step 2: Emergency Needle Decompression
- Prepare equipment:
- Identify insertion site:
- Perform needle decompression:
Step 3: Confirm Successful Decompression
- Signs of successful decompression include:
- Audible hiss of escaping air
- Decreased respiratory distress
- Improved oxygen saturation
- Improvement in signs of shock 4
- If no improvement after first attempt, consider a second needle decompression 4
Step 4: Definitive Management with Chest Tube
- Prepare for chest tube insertion while the decompression cannula remains in place 1
- Insert an intercostal tube into the pleural space using standard technique 1
- Leave the decompression cannula in place until bubbling is confirmed in the underwater seal system, confirming proper function of the intercostal tube 1
- Connect to underwater seal drainage system 1
Step 5: Post-Procedure Care
- Obtain chest radiograph to confirm tube position and lung re-expansion 1
- Provide adequate analgesia 1
- Monitor vital signs and respiratory status 1, 2
- Assess for persistent air leak or complications 1
Special Considerations
- In patients with traumatic cardiac arrest with torso trauma, perform needle decompression on both sides of the chest 4
- After two unsuccessful needle decompressions, proceed to evaluate for other causes of shock, particularly hemorrhage 4
- For refractory cases with persistent shock after two needle decompressions, consider finger thoracostomy or formal chest tube placement if provider has appropriate skills and authorization 4
- Be aware that chest wall thickness may exceed standard needle length in some patients - population studies suggest a 7 cm needle would successfully decompress >90% of patients 3
- Small, undetected pneumothoraces can rapidly progress to tension pneumothorax when positive pressure ventilation is applied during general anesthesia 5
Common Pitfalls to Avoid
- Delaying treatment while waiting for radiographic confirmation - tension pneumothorax is a clinical diagnosis requiring immediate intervention 1
- Using needles that are too short - chest wall thickness often exceeds 3 cm, making standard needles ineffective 1, 3
- Failing to consider tension pneumothorax in patients with unexplained shock, especially in ventilated patients 2, 5
- Removing the decompression cannula before a functioning chest tube is in place 1
- Failing to consider bilateral decompression in traumatic cardiac arrest 4