What is the treatment for tension pneumothorax?

Treatment of Tension Pneumothorax

Immediately administer high-concentration oxygen and perform needle decompression using a cannula at least 4.5 cm in length (preferably 7 cm or longer) inserted at the second intercostal space in the midclavicular line, followed by definitive chest tube placement. 1, 2

Immediate Life-Saving Intervention

Step 1: Oxygen Administration

• Provide high-concentration oxygen immediately upon suspicion of tension pneumothorax 1, 2
• Do not delay treatment to obtain radiographic confirmation—this is a clinical diagnosis based on progressive dyspnea, absent breath sounds on the affected side, tachycardia, hypotension, and respiratory distress 2

Step 2: Needle Decompression (Needle Thoracocentesis)

• Insert a large-bore cannula at the second intercostal space in the midclavicular line 1, 2
• Use a cannula length of at least 4.5 cm, though 7 cm or longer is strongly recommended 1, 3
  • The traditional 4.5 cm needle fails in 9.9-35.4% of patients depending on age, sex, and body habitus 4
  • In 57% of patients, chest wall thickness exceeds 3 cm, making standard needles inadequate 1
  • Population-based data shows mean chest wall thickness is 5.1 cm, with a 7 cm needle successfully decompressing over 90% of patients 3
• Leave the cannula in place until a functioning chest tube is positioned 1, 2
• If available, attach a valve to the end of the puncture needle 1

Step 3: Definitive Management with Chest Tube

• Insert an intercostal chest tube (chest drain) as soon as possible after initial decompression 1, 2
• The cannula must remain in place until bubbling is confirmed in the underwater seal system, confirming proper chest tube function 1
• Monitor closely after decompression; if symptoms of tension pneumothorax recur, repeat needle decompression or proceed directly to tube thoracostomy 1, 2

Critical Clinical Pitfalls to Avoid

Needle Length Inadequacy

• The most common cause of needle decompression failure is insufficient needle length 1, 4, 3
• Women and patients with higher body mass index have significantly greater chest wall thickness and higher failure rates with standard 4.5 cm needles 4
• Using needles shorter than 4.5 cm is associated with failure rates up to 40% 4

Anatomical Considerations

• Insert the needle over the top of the rib to avoid the neurovascular bundle that runs underneath each rib 5
• The internal mammary artery is located medial to the intended puncture site with a mean distance of 5.5-5.7 cm, providing adequate safety margin when using the correct anatomical landmark 3

Special Populations Requiring Immediate Chest Tube

• Patients on positive pressure ventilation (mechanical ventilation or non-invasive ventilation) should receive a chest drain immediately unless immediate weaning is possible, as positive pressure maintains the air leak 1
• Small undetected pneumothoraces can rapidly progress to tension pneumothorax under positive pressure ventilation during general anesthesia 6

Delayed Recognition

• Tension pneumothorax is frequently missed in ICU settings and should be particularly suspected in mechanically ventilated patients who suddenly deteriorate or develop pulseless electrical activity arrest 1
• Tracheal deviation is a late sign indicating prolonged tension development; do not wait for this finding 5
• The development of tension is not dependent on pneumothorax size, and clinical findings may correlate poorly with chest radiography 1

Monitoring After Intervention

• Closely observe for recurrence of symptoms including progressive dyspnea, respiratory distress, hypotension, or increased airway pressures on the ventilator 1, 2, 6
• If respiratory distress persists or worsens after needle decompression, consider massive hemothorax and proceed with tube thoracostomy 1