What is the management of tension pneumothorax?

Tension Pneumothorax Management

Immediate needle decompression with a cannula of at least 4.5-7 cm length at the second intercostal space in the mid-clavicular line, followed by chest tube placement, is the definitive management for tension pneumothorax. 1

Recognition and Diagnosis

• Tension pneumothorax occurs when intrapleural pressure exceeds atmospheric pressure throughout the respiratory cycle, creating a one-way valve effect that traps air in the pleural space 2
• Clinical presentation includes rapid labored breathing, cyanosis, sweating, tachycardia, progressive respiratory distress, and hypoxemia 1
• The diagnosis is primarily clinical and should be particularly suspected in patients on mechanical ventilation or non-invasive ventilation who suddenly deteriorate 2, 3
• The development of tension pneumothorax may correlate poorly with radiographic findings, so do not delay treatment while waiting for imaging confirmation 1

Emergency Management Algorithm

1. Immediate Decompression:

   • Insert a cannula of adequate length (minimum 4.5 cm, preferably 7 cm) into the second intercostal space in the mid-clavicular line 2
   • Recent meta-analysis data suggests a 7 cm needle may be more appropriate as it reduces failure rates by approximately 7.76% per cm of additional length 2
   • Studies show that chest wall thickness often exceeds 3 cm in 57% of patients, making standard shorter needles ineffective 2, 4

2. Technique:

   • Insert the cannula perpendicular to the chest wall and advance it fully to the hub 1
   • Hold the needle/catheter unit in place for 5-10 seconds before removing the needle 1
   • Leave the decompression cannula in place until a chest tube is inserted and functioning properly 2

3. Definitive Management:

   • After needle decompression, immediately proceed to chest tube insertion 2, 1
   • Connect the chest tube to an underwater seal drainage system 1
   • Confirm proper function by observing bubbling in the underwater seal system 2

Alternative Decompression Sites

• The 5th intercostal space along the midaxillary line (5MAL) may be considered for right-sided tension pneumothorax 2
• For left-sided cases, the 2nd intercostal space along the midclavicular line (2MCL) is safer due to potential risk of cardiac injury with lateral approaches 2
• Studies show failure rates of needle decompression at the 2nd ICS MCL range from 39% to 76%, highlighting the importance of using adequate needle length 5

Special Considerations

• Patients on positive pressure ventilation who develop pneumothorax should always receive tube thoracostomy as positive pressure maintains the air leak 2, 6
• Tension pneumothorax can develop rapidly from a simple pneumothorax in patients under positive pressure ventilation during general anesthesia 6
• Higher mortality is associated with tension pneumothorax in mechanically ventilated patients who have higher APACHE II scores or PaO2/FiO2 < 200 mmHg 3

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 - population-based studies recommend 7 cm needles to successfully decompress more than 90% of patients 4
• Removing the decompression cannula before a functioning chest tube is in place 1
• Failing to recognize tension pneumothorax in patients with normal preoperative assessments who deteriorate during anesthesia induction 6

Post-Procedure Care

• Obtain a chest radiograph to confirm tube position and lung re-expansion 1
• Provide adequate analgesia and monitor vital signs and respiratory status 1
• Assess for persistent air leak or complications 1