What is the treatment for tension pneumothorax?

Tension Pneumothorax Treatment

Immediately perform needle decompression with a cannula at least 4.5 cm in length (though 7 cm is strongly preferred) inserted at the second intercostal space in the midclavicular line, followed by definitive chest tube placement—do not delay for radiographic confirmation as this is a clinical diagnosis requiring immediate intervention. 1, 2

Immediate Life-Saving Intervention

Needle Decompression Technique

• Administer high-concentration oxygen immediately while preparing for needle decompression 1
• Use a cannula of at least 4.5 cm length, but 7 cm or longer is strongly recommended to ensure adequate penetration through the chest wall, as standard shorter needles fail in 24-35% of women and 10-19% of men due to chest wall thickness often exceeding 3-4.5 cm 1, 2, 3
• Insert the cannula at the second intercostal space in the midclavicular line, advancing it perpendicular to the chest wall fully to the hub and holding for 5-10 seconds before removing the needle 2
• Use a minimum 14-gauge catheter to allow adequate air evacuation 2
• Attach a valve to the end of the puncture needle if available to prevent air from re-entering the chest cavity during decompression 1

Alternative Decompression Site

• Consider the 5th intercostal space along the midaxillary line for right-sided tension pneumothorax, as cadaveric studies demonstrate 100% success rate at this location versus only 58% at the traditional second intercostal space due to thinner chest wall (3.5 cm vs 4.5 cm) 2, 4
• For left-sided cases, the 2nd intercostal space midclavicular line is safer due to potential cardiac injury risk with lateral approaches 2

Definitive Management

Chest Tube Placement

• Leave the decompression cannula in place until a functioning chest tube is inserted, confirmed by observing bubbling in the underwater seal system 1, 2
• Use a small-bore catheter (≤14F) or 16-22F chest tube for most patients, reserving 24-28F tubes only for large bronchopleural fistula or positive-pressure ventilation 2
• Connect the chest tube to an underwater seal drainage system immediately after placement 2

Special Considerations for Mechanically Ventilated Patients

• Patients on positive pressure ventilation must receive immediate chest tube placement (not just needle decompression) as positive pressure maintains the air leak and can convert a simple pneumothorax to tension pneumothorax 1, 5
• Suspect tension pneumothorax in any mechanically ventilated patient who suddenly deteriorates or develops pulseless electrical activity arrest, as it is frequently missed in ICU settings 1, 2

Critical Pitfalls to Avoid

Needle Length Failure

• Insufficient needle length is the most common cause of needle decompression failure, with failure rates of 26-64% reported when using standard 4.5 cm needles due to mechanical obstruction (kinking, dislodgment) or inadequate chest wall penetration 1, 3, 6
• Never use needles shorter than 4.5 cm, as this is associated with prohibitively high failure rates 1

Diagnostic Delays

• Never delay treatment to obtain radiographic confirmation, as tension pneumothorax is a clinical diagnosis based on progressive dyspnea, respiratory distress, absent breath sounds on the affected side, hypotension, and cardiovascular collapse 1, 2
• Clinical findings correlate poorly with chest radiography, and tension can develop regardless of pneumothorax size 1

Premature Cannula Removal

• Do not remove the decompression cannula before a functioning chest tube is in place, as this can lead to rapid re-accumulation of tension 2

Post-Intervention Monitoring

Immediate Assessment

• Obtain a chest radiograph to confirm tube position and lung re-expansion after chest tube placement 2
• Provide adequate analgesia as part of standard post-insertion care 2

Surveillance for Recurrence

• Monitor closely for recurrence of symptoms including progressive dyspnea, respiratory distress, hypotension, or increased airway pressures on the ventilator, as 32% of patients require subsequent intervention after initial needle decompression 1, 2
• If respiratory distress persists or worsens after needle decompression, consider massive hemothorax and proceed immediately with tube thoracostomy 1
• Perform repeat needle decompression or tube thoracostomy if tension physiology recurs 2