eMedicine Specialties > Trauma > Thoracic Trauma

Tension Pneumothorax: Treatment

Author: H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
Contributor Information and Disclosures

Updated: May 15, 2009

Treatment

Medical Therapy

No acceptable noninvasive therapy exists for this emergent life-threatening condition.

Surgical Therapy

Tension pneumothorax is a life-threatening condition that demands urgent management. If this diagnosis is suspected, do not delay treatment in the interest of confirming the diagnosis.

  • Immediately place the patient on 100% oxygen. Perform emergency needle decompression without hesitation (see Image 1 or below). These steps are often performed before the patient reaches the hospital.
    This picture shows a chest radiograph with 2 abno...

    This picture shows a chest radiograph with 2 abnormalities: (1) tension pneumothorax and (2) potentially life-saving intervention delayed while waiting for x-ray results. Tension pneumothorax is a clinical diagnosis requiring emergent needle decompression, and therapy should never be delayed for x-ray confirmation.

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    This picture shows a chest radiograph with 2 abno...

    This picture shows a chest radiograph with 2 abnormalities: (1) tension pneumothorax and (2) potentially life-saving intervention delayed while waiting for x-ray results. Tension pneumothorax is a clinical diagnosis requiring emergent needle decompression, and therapy should never be delayed for x-ray confirmation.

  • After needle decompression, immediately begin preparation to insert a thoracostomy tube. Then, reassess the patient, paying careful attention to the ABCs (ie, airway, breathing, circulation) of trauma management. An element of hemothorax along with the tension pneumothorax is common; therefore, the patient may require additional thoracostomy tubes.
  • Obtain a follow-up chest x-ray to assess for lung reexpansion, thoracostomy tube positioning, and to correct any mediastinum deviation (see Images 5-6 or below). Additionally, follow-up arterial blood gases may be ordered.
    An older man was admitted to the intensive care u...

    An older man was admitted to the intensive care unit (ICU) postoperatively. Note the right-sided pneumothorax induced by the incorrectly positioned small-bowel feeding tube in the right-sided bronchial tree. Marked depression of the right hemidiaphragm is noted, and mediastinal shift is to the left side, suggestive of tension pneumothorax. The endotracheal tube is in a good position.

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    An older man was admitted to the intensive care u...

    An older man was admitted to the intensive care unit (ICU) postoperatively. Note the right-sided pneumothorax induced by the incorrectly positioned small-bowel feeding tube in the right-sided bronchial tree. Marked depression of the right hemidiaphragm is noted, and mediastinal shift is to the left side, suggestive of tension pneumothorax. The endotracheal tube is in a good position.


    Right main stem intubation resulting in left-side...

    Right main stem intubation resulting in left-sided tension pneumothorax, right mediastinal shift, deep sulcus sign, and subpulmonic pneumothorax.

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    Right main stem intubation resulting in left-side...

    Right main stem intubation resulting in left-sided tension pneumothorax, right mediastinal shift, deep sulcus sign, and subpulmonic pneumothorax.

  • Monitor the patient continuously for arterial oxygen saturation.
  • Admit all patients with tension pneumothorax.

Emergent needle decompression

The basic principle or emergent needle decompression is to introduce a catheter into the pleural space, thus producing a pathway for the air to escape and relieving the built-up pressure. Although this procedure is not the definitive treatment for tension pneumothorax, emergent needle decompression does arrest its progression and serves to restore cardiopulmonary function slightly. Needle length in persons with large pectoral muscles may be an issue, and long needles or angiocatheters may be necessary.16,17,18

  • Administer 100% oxygen, and ventilate the patient if necessary.
  • Locate anatomic landmarks and quickly prepare the area to be punctured with an iodine-based solution (eg, Betadine).
  • Insert a large-bore (ie, 14-gauge or 16-gauge) needle with a catheter into the second intercostal space, just superior to the third rib at the midclavicular line, 1-2 cm from the sternal edge (ie, to avoid injury to the internal thoracic artery). Use a catheter or needle >4.5 cm long, and hold it perpendicular to the chest wall when inserting; however, note that some patients may have a chest wall thickness greater than 4.5 cm, and failure for the symptoms to resolve may be attributed to inadequate needle length.16,17,18
  • Once the needle is in the pleural space, listen for the hissing sound of air escaping, and remove the needle while leaving the catheter in place.
  • Secure the catheter in place, and install a flutter valve.
  • Prepare the patient for tube thoracostomy.

Tube thoracostomy

  • Tube thoracostomy is the definitive treatment for tension pneumothorax, and needle decompression mandates an immediate follow up with a tube thoracostomy.
  • Sedate the patient consciously; narcotics are optional and may not be necessary.
  • Locate anatomic landmarks, and administer a local anesthetic.
  • Prepare the area with an iodine solution (eg, Betadine) and drape.
  • Create a 3-cm horizontal incision in the skin, over the fifth or sixth rib along the midaxillary line.
  • Use a curved hemostat and dissect through the soft tissue and down to the rib.
  • Push the hemostat just over the superior portion of the rib, avoiding the intercostal neurovascular bundle that runs under the inferior portion of the next most superior rib. Then, puncture the intercostal muscles and parietal pleura.
  • Maintain the intrapleural position by inserting a finger along side of the hemostat, and remove the hemostat.
  • Insert the chest tube over the finger into the pleural space. A clamp may suffice for guiding the thoracostomy tube into place on the proximal end.
  • Look for condensation in the tube as a sign of correct placement and air evacuation.
  • Connect the thoracostomy tube to an underwater seal apparatus and suction.
  • Suture the tube in place, dress the wound, and tape the tube to the chest.
  • Obtain a follow-up chest x-ray to assess tube positioning and lung reexpansion.

Follow-up

While the patient is on positive-pressure ventilation and normal respiratory function is preserved, routinely follow up decompressed tension pneumothoraces by watching for recurrence of the condition. Chest x-ray is helpful but not required.

Complications

Misdiagnosis is the most common complication of needle decompression. If a pneumothorax but not a tension pneumothorax is present, needle decompression converts it to an open pneumothorax.

If no pneumothorax exists, the patient may develop a pneumothorax after the needle decompression is performed. Additionally, the needle may lacerate a lung, which, although rare, can cause significant pulmonary injury or hemothorax. If the needle is initially placed too medially to the sternum, needle decompression may cause a hemothorax by lacerating the inferior set of intercostal vessels or the internal mammary artery.

Thoracostomy tube placement can result in damage to the intercostal neurovascular bundle and can cause lung parenchymal injury, especially if using trocars for its placement.

More on Tension Pneumothorax

Overview: Tension Pneumothorax
Workup: Tension Pneumothorax
Treatment: Tension Pneumothorax
Follow-up: Tension Pneumothorax
Multimedia: Tension Pneumothorax
References
Further Reading
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References

  1. McPherson JJ, Feigin DS, Bellamy RF. Prevalence of tension pneumothorax in fatally wounded combat casualties. J Trauma. Mar 2006;60(3):573-8. [Medline].

  2. Plewa MC, Ledrick D, Sferra JJ. Delayed tension pneumothorax complicating central venous catheterization and positive pressure ventilation. Am J Emerg Med. Sep 1995;13(5):532-5. [Medline].

  3. Miller JS, Itani KM, Oza MD, Wall MJ. Gastric rupture with tension pneumoperitoneum: a complication of difficult endotracheal intubation. Ann Emerg Med. Sep 1997;30(3):343-6. [Medline].

  4. Hashmi S, Rogers SO. Tension pneumothorax with pneumopericardium. J Trauma. Jun 2003;54(6):1254. [Medline].

  5. Iannoli ED, Litman RS. Tension pneumothorax during flexible fiberoptic bronchoscopy in a newborn. Anesth Analg. Mar 2002;94(3):512-3; table of contents. [Medline]. [Full Text].

  6. Peuker E. Case report of tension pneumothorax related to acupuncture. Acupunct Med. Mar 2004;22(1):40-3. [Medline]. [Full Text].

  7. Whale C, Hallam C. Tension pneumothorax related to acupuncture. Acupunct Med. Jun 2004;22(2):101; author reply 101-2. [Medline]. [Full Text].

  8. Zhao DY, Zhang GL. [Clinical analysis on 38 cases of pneumothorax induced by acupuncture or acupoint injection] [Chinese]. Zhongguo Zhen Jiu. Mar 2009;29(3):239-42. [Medline].

  9. Dalton AM, Hodgson RS, Crossley C. Bochdalek hernia masquerading as a tension pneumothorax. Emerg Med J. May 2004;21(3):393-4. [Medline]. [Full Text].

  10. Hearnshaw SA, Oppong K, Jaques B, Thompson NP. Tension pneumothorax as a complication of colonoscopy. Endoscopy. Feb 2004;36(2):190. [Medline]. [Full Text].

  11. Brander L, Takala J. Tracheal tear and tension pneumothorax complicating bronchoscopy-guided percutaneous tracheostomy. Heart Lung. Mar-Apr 2006;35(2):144-5. [Medline].

  12. Wax DB, Leibowitz AB. Radiologic assessment of potential sites for needle decompression of a tension pneumothorax. Anesth Analg. Nov 2007;105(5):1385-8, table of contents. [Medline]. [Full Text].

  13. Dente CJ, Ustin J, Feliciano DV, et al. The accuracy of thoracic ultrasound for detection of pneumothorax is not sustained over time: a preliminary study. J Trauma. Jun 2007;62(6):1384-9. [Medline].

  14. Knudtson JL, Dort JM, Helmer SD, Smith RS. Surgeon-performed ultrasound for pneumothorax in the trauma suite. J Trauma. Mar 2004;56(3):527-30. [Medline].

  15. Dulchavsky SA, Schwarz KL, Kirkpatrick AW, et al. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma. Feb 2001;50(2):201-5. [Medline].

  16. Zengerink I, Brink PR, Laupland KB, et al. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle?. J Trauma. Jan 2008;64(1):111-4. [Medline].

  17. Britten S, Palmer SH, Snow TM. Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure. Injury. Jun 1996;27(5):321-2. [Medline].

  18. Marinaro JL, Kenny CV, Smith SR, et al. Needle thoracostomy in trauma patients: what catheter length is adequate?. Acad Emerg Med. (2003 May) 10(5):495.

  19. Barton ED, Epperson M, Hoyt DB, Fortlage D, Rosen P. Prehospital needle aspiration and tube thoracostomy in trauma victims: a six-year experience with aeromedical crews. J Emerg Med. Mar-Apr 1995;13(2):155-63. [Medline].

  20. Barton ED, Rhee P, Hutton KC, Rosen P. The pathophysiology of tension pneumothorax in ventilated swine. J Emerg Med. Mar-Apr 1997;15(2):147-53. [Medline].

  21. Beards SC, Lipman J. Decreased cardiac index as an indicator of tension pneumothorax in the ventilated patient. Anaesthesia. Feb 1994;49(2):137-41. [Medline].

  22. Behnia MM, Garrett K. Association of tension pneumothorax with use of small-bore chest tubes in patients receiving mechanical ventilation. Crit Care Nurse. Feb 2004;24(1):64-5. [Medline]. [Full Text].

  23. Butler KL, Best IM, Weaver WL, Bumpers HL. Pulmonary artery injury and cardiac tamponade after needle decompression of a suspected tension pneumothorax. J Trauma. Mar 2003;54(3):610-1. [Medline].

  24. Campbell-Smith TA, Bendall SP, Davis J. Tension pneumothorax in the presence of bilateral intercostal chest drains. Injury. Sep 1998;29(7):556-7. [Medline].

  25. Childs SG. Tension pneumothorax: a pulmonary complication secondary to regional anesthesia from brachial plexus interscalene nerve block. J Perianesth Nurs. Dec 2002;17(6):404-10; quiz 410-2. [Medline].

  26. Clark S, Ragg M, Stella J. Is mediastinal shift on chest X-ray of pneumothorax always an emergency?. Emerg Med (Fremantle). Oct-Dec 2003;15(5-6):429-33. [Medline].

  27. Clasen S, Kettenbach J, Kosan B, et al. Delayed Development of Pneumothorax After Pulmonary Radiofrequency Ablation. Cardiovasc Intervent Radiol. Jan 7 2009;epub ahead of print. [Medline].

  28. Friend KD. Prehospital recognition of tension pneumothorax. Prehosp Emerg Care. Jan-Mar 2000;4(1):75-7. [Medline].

  29. Gordon AH, Grant GP, Kaul SK. Reexpansion pulmonary edema after resolution of tension pneumothorax in the contralateral lung of a previously lung injured patient. J Clin Anesth. Jun 2004;16(4):289-92. [Medline].

  30. Harcke HT, Pearse LA, Levy AD, Getz JM, Robinson SR. Chest wall thickness in military personnel: implications for needle thoracentesis in tension pneumothorax. Mil Med. Dec 2007;172(12):1260-3. [Medline].

  31. Hostetler MA, Davis CO. Bilateral localized tension pneumothoraces refractory to needle decompression. Pediatr Emerg Care. Oct 1999;15(5):322-4. [Medline].

  32. Jones R, Hollingsworth J. Tension pneumothoraces not responding to needle thoracocentesis. Emerg Med J. Mar 2002;19(2):176-7. [Medline]. [Full Text].

  33. Kaye W. Invasive therapeutic techniques: emergency cardiac pacing, pericardiocentesis, intracardiac injections, and emergency treatment of tension pneumothorax. Heart Lung. May 1983;12(3):300-19. [Medline].

  34. Lee HC, Dewan N, Crosby L. Subcutaneous emphysema, pneumomediastinum, and potentially life-threatening tension pneumothorax. Pulmonary complications from arthroscopic shoulder decompression. Chest. May 1992;101(5):1265-7. [Medline]. [Full Text].

  35. Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think?. Emerg Med J. Jan 2005;22(1):8-16. [Medline]. [Full Text].

  36. McSwain NE Jr. The McSwain Dart: device for relief of tension pneumothorax. Med Instrum. Sep-Oct 1982;16(5):249-50. [Medline].

  37. Netto FA, Shulman H, Rizoli SB, et al. Are needle decompressions for tension pneumothoraces being performed appropriately for appropriate indications?. Am J Emerg Med. Jun 2008;26(5):597-602. [Medline].

  38. Rawlins R, Brown KM, Carr CS, Cameron CR. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J. Jul 2003;20(4):383-4. [Medline]. [Full Text].

  39. Schuurmans MM, Davel S, Diacon AH. Non-responding 'tension pneumothorax' following stab wounds. Respiration. Jan-Feb 2003;70(1):100. [Medline]. [Full Text].

  40. Stevens RL, Rochester AA, Busko J, et al. Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography. Prehosp Emerg Care. Jan-Mar 2009;13(1):14-7. [Medline].

  41. Vermillion JM, Wilson EB, Smith RW. Traumatic diaphragmatic hernia presenting as a tension fecopneumothorax. Hernia. Sep 2001;5(3):158-60. [Medline].

  42. Vinson ED. Improvised chest tube drain for decompression of an acute tension pneumothorax. Mil Med. May 2004;169(5):403-5. [Medline].

  43. Watts BL, Howell MA. Tension pneumothorax: a difficult diagnosis. Emerg Med J. Jul 2001;18(4):319-20. [Medline]. [Full Text].

  44. [Best Evidence] Joshi GP, Bonnet F, Shah R, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg. Sep 2008;107(3):1026-40. [Medline].

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Further Reading

Related eMedicine Topics

Clinical Trials

National Guideline Clearinghouse

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Keywords

tension pneumothorax, pneumothorax, collapsed lung, lung collapse, pneumomediastinum, air in intrapleural space, blunt chest injury, penetrating chest injury, needle thoracostomy, tube thoracostomy, chest tube, tension percutaneous aspiration, chest trauma, transthoracic needle aspiration, therapeutic thoracentesis, central venous catheter insertion, positive pressure mechanical ventilation, intrapleural air, perivascular alveolar rupture

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Contributor Information and Disclosures

Author

H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Marc D Basson, MD, PhD, MBA, Professor, Chair, Department of Surgery, Michigan State University
Marc D Basson, MD, PhD, MBA is a member of the following medical societies: American College of Surgeons and American Gastroenterological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School
Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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