From the Guidelines
Emergent pneumothorax is a life-threatening condition that presents with sudden onset of sharp chest pain, progressive shortness of breath, and signs of respiratory distress, requiring immediate recognition and treatment to prevent morbidity and mortality. The signs and symptoms of emergent pneumothorax include:
- Sudden onset of sharp chest pain that worsens with breathing and coughing
- Progressive shortness of breath
- Decreased breath sounds, hyperresonance to percussion, and decreased chest wall movement on the affected side
- Tracheal deviation away from the affected side, distended neck veins, and hemodynamic instability with hypotension and tachycardia in tension pneumothorax
- Cyanosis and altered mental status may develop as hypoxemia worsens
- Subcutaneous emphysema (air under the skin) that feels like crepitus on palpation These symptoms result from air accumulation in the pleural space, causing lung collapse and potentially compromising cardiopulmonary function by preventing normal lung expansion and reducing venous return to the heart 1. The diagnosis of tension pneumothorax can be made based on clinical signs, including:
- History of chest injury
- Progressive difficulty breathing
- Attenuated or absent breath sound on the side of the injury
- Elevated chest wall on the side of the injury compared with the contralateral side, subcutaneous emphysema, and jugular vein distension
- Hypotension and shock induced by tachycardia and shortness of breath 1. Immediate recognition is crucial as tension pneumothorax requires emergency needle decompression followed by chest tube placement to relieve pressure and allow lung re-expansion 1. The use of ultrasound in the diagnosis of tension pneumothorax has been shown to have high sensitivity and specificity, and can be a useful tool in the emergency setting 1. In the treatment of emergent pneumothorax, the use of a 3.25-in.-long (8.25 cm) puncture needle is recommended for needle thoracentesis, and the placement of a chest tube should be considered after needle decompression 1.
From the Research
Signs and Symptoms of Emergent Pneumothorax
- Dyspnea, or difficulty breathing, is a common symptom of pneumothorax 2
- Chest pain is also a frequent finding in patients with pneumothorax 2
- Tachypnea, or rapid breathing, can be observed in patients with pneumothorax 2
- Absent breath sounds on lung auscultation can indicate pneumothorax 2
- Hemodynamic instability can occur in severe cases of pneumothorax, particularly tension pneumothorax 3, 4
Diagnosis of Emergent Pneumothorax
- Portable ultrasonography can be used to rapidly diagnose pneumothorax with higher sensitivity than plain film 2
- Plain film and CT scans are traditional methods for diagnosing pneumothorax, but may not be as sensitive as ultrasonography 2
- Clinical correlation with catheter length is important for successful needle decompression in tension pneumothorax 4
Management of Emergent Pneumothorax
- Needle decompression or tube thoracostomy are common treatments for traumatic pneumothorax 2
- Conservative management via observation or smaller thoracostomy, such as a percutaneous pigtail catheter, may be suitable for some patients 2
- Prehospital needle chest decompression (NCD) can be effective using a needle >7cm length with either a lateral or anterior approach 5
- Finger thoracostomy (FT) is an interesting diagnostic and therapeutic approach, but evidence on success rates and complications is limited 5