Decompress the Tension Pneumothorax First, Before Intubation
In a patient requiring both intubation and chest decompression for tension pneumothorax, you must perform immediate needle decompression BEFORE attempting intubation, as positive pressure ventilation will dramatically worsen the tension pneumothorax and can precipitate cardiovascular collapse or cardiac arrest. 1, 2, 3
Critical Pathophysiology
Tension pneumothorax creates a one-way valve mechanism where air enters the pleural space during inspiration but cannot escape during expiration, progressively increasing intrapleural pressure 1, 2
Positive pressure ventilation from intubation will maintain and accelerate the air leak, converting a manageable pneumothorax into a life-threatening tension pneumothorax within seconds 1, 3
An undetected small pneumothorax without symptoms can rapidly progress to tension pneumothorax through positive pressure ventilation during general anesthesia, creating immediate hemodynamic collapse 3
The Correct Sequence
Step 1: Immediate Needle Decompression
Insert a cannula of adequate length (minimum 4.5 cm, preferably 7-8.25 cm) into the second intercostal space at the midclavicular line 4, 1, 2
Insert the needle/catheter unit perpendicular to the chest wall all the way to the hub, then hold it in place for 5-10 seconds before removing the needle to allow full decompression 2, 5
A 14-gauge needle is standard, though 10-gauge may be considered as an alternative 5
Leave the decompression cannula in place throughout the intubation procedure until a functioning chest tube is positioned and bubbling is confirmed in the underwater seal system 1, 2
Step 2: Proceed with Intubation
Only after successful needle decompression (confirmed by a hiss of air, decreased respiratory distress, improved oxygen saturation, or improvement in shock signs) should you proceed with intubation 5
The patient on mechanical ventilation will always require definitive tube thoracostomy, as positive pressure maintains the air leak 1, 2
Step 3: Definitive Chest Tube Placement
Place a chest tube in the fourth/fifth intercostal space at the midaxillary line connected to an underwater seal drainage system 4, 2
Confirm proper tube position and lung re-expansion with chest radiography 2
Common Pitfalls to Avoid
Never delay needle decompression to obtain radiographic confirmation—tension pneumothorax is a clinical diagnosis requiring immediate intervention based on progressive dyspnea, attenuated breath sounds, tachycardia, and respiratory distress 4, 2
Never intubate first and decompress later—this sequence will worsen the tension and may cause immediate cardiac arrest 1, 3
Avoid using needles that are too short, as chest wall thickness exceeds 5 cm in many patients, making standard 5 cm needles ineffective in up to 57% of cases 4, 2
Do not remove the decompression cannula before a functioning chest tube is in place 1, 2
If two needle decompressions fail to improve the clinical picture, proceed to evaluate and treat for hemorrhagic shock while considering finger thoracostomy or tube thoracostomy if you have the skills and the patient remains in refractory shock 5