What is the most appropriate initial step in management for a patient who develops shortness of breath, decreased breath sounds, jugular venous distention, and hypotension following placement of a central line (central venous catheter)?

Immediate Needle Decompression for Tension Pneumothorax

Perform immediate needle decompression without waiting for chest x-ray confirmation. This patient presents with the classic triad of tension pneumothorax following central line placement: hypotension, decreased breath sounds, and jugular venous distention (JVD), which represents a life-threatening emergency requiring immediate intervention 1, 2.

Clinical Recognition and Pathophysiology

The combination of hypotension, decreased right-sided breath sounds, JVD, and shortness of breath following subclavian line placement is pathognomonic for tension pneumothorax. This occurs when air accumulates in the pleural space under pressure, causing:

• Mediastinal shift with compression of the contralateral lung
• Decreased venous return manifesting as JVD and hypotension
• Cardiovascular collapse if untreated 3

The hypotension with elevated JVD distinguishes this from hypovolemic shock (which would present with flat neck veins) and confirms the diagnosis of obstructive shock from tension physiology 1, 2.

Immediate Management Algorithm

Step 1: Needle Decompression (DO NOT DELAY)

• Perform immediate needle decompression at the 2nd intercostal space, midclavicular line on the affected (right) side
• Use a large-bore (14-16 gauge) catheter
• This is a clinical diagnosis—do NOT wait for chest x-ray confirmation as delay increases mortality 3
• A rush of air confirms the diagnosis and provides immediate life-saving decompression

Step 2: Supplemental Oxygen

• Administer high-flow oxygen (not 100% oxygen, which can worsen pneumothorax absorption) to maintain SpO2 >90% 4, 5
• Oxygen should be titrated to clinical response, not given indiscriminately at 100% 4

Step 3: Definitive Management

• After needle decompression stabilizes the patient, place a chest tube (small gauge drain is usually adequate) for definitive treatment 3
• Obtain chest x-ray AFTER needle decompression to confirm tube placement and lung re-expansion 3

Step 4: Central Line Management

• The central line can remain in place if functioning properly and not malpositioned
• Prompt removal is NOT indicated unless the catheter is malpositioned or contributing to ongoing air leak 3

Critical Pitfalls to Avoid

Never observe or obtain imaging first in a patient with clinical tension pneumothorax—this is a clinical diagnosis requiring immediate intervention. Waiting for chest x-ray confirmation in the presence of hemodynamic instability significantly increases mortality risk 3.

Do not administer 100% oxygen and observe (Option A)—while oxygen is appropriate, observation without decompression in tension pneumothorax is fatal. Studies show 100% oxygen does not hasten pneumothorax resolution and may prolong unnecessary oxygen exposure 4.

Do not obtain chest x-ray first (Option B)—imaging delays life-saving intervention. Most pneumothoraces are detected on 1-hour post-procedure films, but tension pneumothorax requires immediate decompression before any imaging 3.

Do not remove the central line first (Option D)—this wastes critical time and does not address the tension physiology. The pneumothorax has already occurred; removing the catheter will not decompress the pleural space 3.

Post-Decompression Monitoring

After successful needle decompression and chest tube placement:

• Monitor with serial chest x-rays (initially at 1 hour, then daily) 3
• Attach chest tube to underwater seal or Heimlich valve 3
• Watch for complications including re-expansion pulmonary edema, persistent air leak, or surgical emphysema 3
• Most small residual pneumothoraces resolve spontaneously after tube drainage 3