Tension Pneumothorax: Immediate Treatment
For suspected tension pneumothorax, perform immediate needle decompression using a 7-8 cm needle (minimum 4.5 cm, 14-gauge) at the 2nd intercostal space in the midclavicular line, followed immediately by chest tube insertion—this is a clinical diagnosis requiring no delay for radiographic confirmation. 1, 2
Clinical Recognition
Tension pneumothorax is a life-threatening emergency where air accumulates under pressure in the pleural space through a one-way valve mechanism, causing cardiovascular collapse. 1, 2
Key diagnostic features include:
- Rapid, labored respiration with progressive respiratory distress 3, 1
- Cyanosis, profuse sweating, and tachycardia 3, 1
- Attenuated or absent breath sounds on the affected side 4, 2
- Sudden deterioration in mechanically ventilated patients or development of pulseless electrical activity (PEA) 3, 1
- Tracheal deviation away from the affected side (late finding) 2
Critical point: This is purely a clinical diagnosis—never delay treatment waiting for chest X-ray confirmation, as this condition is immediately life-threatening. 2
Immediate Needle Decompression
Needle specifications and technique:
- Use a 7-8 cm needle (specifically 8.25 cm recommended), minimum 4.5 cm length, 14-gauge 4, 1, 2
- Standard 5 cm needles fail in 32.84% of cases because chest wall thickness exceeds 3 cm in 57% of patients 1, 2
- Insert at the 2nd intercostal space in the midclavicular line as the primary site 4, 1, 2
- Advance the cannula perpendicular to the chest wall fully to the hub 1
- Hold the needle/catheter unit in place for 5-10 seconds before removing the needle 1
Alternative site considerations:
- For right-sided tension pneumothorax: either 2nd intercostal space midclavicular line OR 5th intercostal space midaxillary line are acceptable 2
- For left-sided tension pneumothorax: use ONLY the 2nd intercostal space midclavicular line due to cardiac injury risk with lateral approaches 2
Leave the decompression cannula in place until a functioning chest tube is inserted and confirmed by observing bubbling in the underwater seal system. 3, 1
Definitive Management: Chest Tube Insertion
Following needle decompression, immediately proceed to tube thoracostomy—the cannula is only a temporizing measure. 1, 2
Chest tube placement:
- Insert at the 4th-5th intercostal space in the midaxillary line 4, 2
- Use small-bore catheter (≤14F) or 16-22F chest tube for most patients 4, 3
- Use 24-28F tube only if large bronchopleural fistula or positive-pressure ventilation is required 4
- Connect to underwater seal drainage system 3, 1
- Confirm proper function by observing bubbling before removing the decompression cannula 3, 1
Post-insertion care:
- Obtain chest radiograph to confirm tube position and lung re-expansion 1
- Provide adequate analgesia 4, 1
- Monitor for persistent air leak or complications 1
Special Clinical Scenarios
Patients on positive-pressure ventilation:
- Always require tube thoracostomy, as positive pressure maintains the air leak 1, 5, 6
- Even small, asymptomatic pneumothoraces can rapidly progress to tension pneumothorax under positive-pressure ventilation 5, 6
- Tension pneumothorax is more common in ventilated patients and carries higher mortality 6
Post-procedure monitoring:
- Monitor closely for recurrence—32% of patients require subsequent intervention after initial needle decompression 2
- Repeat needle decompression or proceed to tube thoracostomy if tension physiology recurs 4, 2
Critical Pitfalls to Avoid
- Never delay treatment for radiographic confirmation—tension pneumothorax is a clinical diagnosis requiring immediate intervention 2
- Never use needles shorter than 7 cm—the traditional 5 cm ATLS recommendation has a 32.84% failure rate due to inadequate chest wall penetration 2
- Never remove the decompression cannula before a functioning chest tube is in place 1
- For left-sided cases, avoid the lateral approach due to cardiac injury risk; use the anterior approach instead 2
- Do not assume normal preoperative assessment excludes risk—undetected small pneumothoraces can progress to tension pneumothorax during anesthesia 5