Tension pneumothorax

Tension pneumothorax is the progressive build-up of air within the pleural space, usually due to a
lung laceration which allows air to escape into the pleural space but not to return. Positive
pressure ventilation may exacerbate this 'one-way-valve' effect.

Progressive build-up of pressure in the pleural space pushes the mediastinum to the opposite
hemithorax, and obstructs venous return to the heart. This leads to circulatory instability and may
result in traumatic arrest. The classic signs of a tension pneumothorax are deviation of the trachea
away from the side with the tension, a hyper-expanded chest, an increased percussion note and a
hyper-expanded chest that moves little with respiration. The central venous pressure is usually
raised, but will be normal or low in hypovolaemic states.

However these classic signs are usually absent and more commonly the patient is tachycardic and
tachypnoeic, and may be hypoxic. These signs are followed by circulatory collapse with
hypotension and subsequent traumatic arrest with pulseless electrical activity (PEA). Breath
sounds and percussion note may be very difficult to appreciate and misleading in the trauma
room.

Tension pneumothorax may develop insidiously, especially in patients with positive pressure
ventilation. This may happen immediately or some hours down the line. An unexplained
tachycardia, hypotension and rise in airway pressure are strongly suggestive of a developing
tension.

The X-ray on the right is a post-mortem film taken in a patient with severe blunt trauma to the
chest and a left tension pneumothorax. It illustrates the classic features of a tension:

 Deviation of the trachea away from the side of the tension.

 Shift of the mediastinum
 Depression of the hemi-diaphragm

With this degree of tension pneumothorax, it is not difficult to appreciate how cardiovascular
function may be compromised by the tension, due to obstruction of venous return to the heart.
This massive tension pneumothorax should indeed have been detectable clinically and, in the face
of haemodynamic collapse, been treated with emergent thoracostomy - needle or otherwise.

A tension pneumothorax may develop while the patient is undergoing investigations, such as CT
scanning (image at right) or operation. Whenever there is deterioration in the patient's
oxygenation or ventilatory status, the chest should be re-examined and tension pneumothorax
excluded.

The presence of chest tubes does not mean a patient cannot develop a tension pneumothorax. The
patient below had a right sided tension despite the presence of a chest tube. It is easy to
appreciate how this may happen on the CT image showing the chest tubes in the oblique fissure.
Chest tubes here, or placed posteriorly, will be blocked as the overlying lung is compressed
backwards. Chest tubes in supine trauma patients should be placed anteriorly to avoid this
complication. Haemothoraces will still be drained provided the lung expands fully.

Tension pneumothorax may also persist if there is an injury to a major airway, resulting in a
bronchopleural fistula. In this case a single chest tube is cannot cope with the major air leak. Two,
three or occasionally more tubes may be needed to manage the air leak. In these cases
thoracotom is usually indicated to repair the airway and resect damaged lung.

Beware also the patient with bilateral tension pneumothoraces. The trachea is central, while
percussion and breath sounds are equal on both sides. These patients are usually
haemodynamically compromised or in traumatic arrest. Emergent bilateral chest decompression
should be part of the procedure for traumatic arrest where this is a possibility.
This (rare) chest X-ray shows the characteristic apparent 'disappearance of the heart' with bilateral
tension pneumothoraces.

Management

Needle Thoracostomy

Classical management of tension pneumothorax is emergent chest decompression with needle

thoracostomy. A 14-16G intravenous cannula is inserted into the second rib space in the mid-
clavicular line. The needle is advanced until air can be aspirated into a syringe connected to the
needle. The needle is withdrawn and the cannula is left open to air. An immediate rush of air out of
the chest indicates the presence of a tension pneumothorax. The manoeuver effectively converts a
tension pneumothorax into a simple pneumothorax.

Many texts will state that a tension pneumothorax is a clinical diagnosis and should be treated with
needle thoracostomy prior to any imaging. Recently this dogma has been called into question.
Needle thoracostomy is probably not as benign an intervention as previously thought, and often is
simply ineffective in relieving a tension pneumothorax. If no rush of air is heard on insertion, it is
impossible to know whether there really was a tension or not, and whether the needle actually
reached the pleural cavity at all. Some heavy-set patients may have very thick chest walls.

Needle thoracostomies are also prone to blockage, kinking, dislodging and falling out. Thus a
relieved tension may re-accumulate undetected. More importantly is the possibility of lung
laceration with the needle, especially if no pneumothorax is present initially. Air embolism through
such a laceration is also a real concern.

In the absence of haemodynamic compromise, it is prudent to wait for the results of an emergent
chest X-ray prior to intervention. This will avoid patients such as that shown at right, where a right
upper lobe collapse due to endobronchial intubation resulted in hypoxia and tracheal deviation -
mimicking a tension pneumothorax on the opposite side The patient received an unnecessary left
chest tube.

The trauma-list has extensively debated needle thoracocentesis and discussions has
been archived. The conclusion of the debate was:

1. Needle decompression can be associated with complications.

2. It should not be used lightly.
3. It should never be used just because we don't hear breath sounds on one side.

BUT

4. In clear cut cases: shock with distended neck veins, reduced breath sounds, deviated trachea,
it could be life saving.

Chest Drain Placement

Chest tube placement is the definitive treatment of traumatic pneumothorax. In most centres,
chest tubes should be immediately available in the resuscitation room and placement is usually
rapid. The controlled placement of a chest tube is preferable to blind needle thoracostomy. This is
provided the patient's respiratory and haemodynamic status will tolerate the extra minutes it takes
to perform the surgical thoracostomy.

Once the pleura is entered (blunt dissection), the tension is decompressed and chest tube
placement can be performed without haste. This is especially true of the patient who is being
manually ventilated with positive pressure, and surgical thoracostomies without chest tube
placement have been described in the prehospital setting.