eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Pneumothorax, Tension and Traumatic: Follow-up

Author: Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Contributor Information and Disclosures

Updated: Feb 5, 2009

Follow-up

Further Inpatient Care

  • If the patient has had repeated episodes of pneumothorax or if the lung remains unexpanded after 5 days with a chest tube in place, surgery may be necessary. The surgeon may use treatment options such as thoracoscopy, electrocautery, laser treatment, resection of blebs or pleura, or open thoracotomy.
  • In patients with repeated pneumothoraces who are not good candidates for surgery, sclerotherapy with talc or doxycycline may be necessary.
  • In a preliminary study by Dente et al, ultrasonographic evaluation for pneumothorax was found to be very accurate for the first 24 hours after insertion of a thoracostomy tube. However, its accuracy is not sustained over time. Twenty-four hours after thoracostomy, diagnostic sensitivity of ultrasonography for pneumothorax fell to 55%, and its positive predictive value to 43%. This may be related to intrapleural adhesion formation.7

Deterrence/Prevention

  • Advise patients to wear safety belts and passive restraint devices while driving.
  • Encourage smoking cessation.
  • The incidence of iatrogenic tension pneumothorax may be decreased with prophylactic insertion of a chest tube in patients with a simple pneumothorax that requires positive pressure ventilation.
  • When subclavian vein cannulation is required, use the supraclavicular approach rather than the infraclavicular approach when possible to help decrease the likelihood of pneumothorax formation.
  • Prompt recognition and treatment of bronchopulmonary infections decreases the risk of progression to a pneumothorax.

Complications

  • Respiratory distress and/or arrest
  • Cardiac arrest
  • Pulmonary edema (following lung reexpansion)
  • Empyema
  • Persistent bronchopulmonary fistula
  • Pneumomediastinum
  • Pneumopericardium
  • Pneumoperitoneum
  • Pyopneumothorax
  • Hemopneumothorax

Prognosis

  • The prognosis is generally good with appropriate therapy, but it varies depending on the etiology.

Miscellaneous

Medicolegal Pitfalls

  • The diagnosis of a tension pneumothorax should largely be made based on the history and physical examination findings. Ultrasonography in the emergency setting is being increasingly used as an adjunct to the physical examination when there is doubt regarding the diagnosis. Chest radiography or CT scanning should be used only in those instances when the clinician is in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable. Obtaining such imaging studies when the diagnosis of tension pneumothorax is not in question causes an unnecessary and potentially lethal delay in treatment.
  • A tension pneumothorax is a life-threatening condition and requires immediate action (eg, needle thoracostomy or chest tube insertion). However, the clinician should be wary of prematurely diagnosing a tension pneumothorax in a patient without respiratory distress, hypoxia, hypotension, or cardiopulmonary compromise. If the patient's clinical presentation is questionable and if the patient appears stable, the clinician should reexamine the patient and use bedside ultrasonography or request immediate portable chest radiography (or reexamine the chest radiographs if they have already been obtained) to confirm the diagnosis.
  • Consider the diagnosis of a pneumothorax and/or tension pneumothorax with blunt and penetrating trauma. In the patient with blunt trauma and mental status changes, hypoxia, and acidosis, symptoms may be attributed to a suspected intracerebral injury rather than a tension pneumothorax. Portable chest radiography should always be included in the initial radiographic evaluation of major trauma. Chest CT scanning should always be performed for significant chest injuries since they carry an estimated risk of associated pneumothorax as high as 50% and about half of these pneumothoraces may be occult.
  • When assessing the trauma patient, be aware that clinical presentations of tension pneumothorax and myocardial rupture with tamponade may be similar.
  • The rare event of spontaneous pneumothorax leading to tension pneumothorax may be misdiagnosed as an asthma crisis or COPD exacerbation in the patient presenting with tachycardia, subcutaneous emphysema, dyspnea, and shock.
  • A significant number of patients have a larger chest wall than can be penetrated by a catheter length of 5 cm. Although thinner patients requiring thoracostomy can be treated using shorter catheter lengths, patients with a body habitus suggestive of a wider chest wall may need a catheter longer than 5 cm to reliably penetrate into the pleural space. In one study, a catheter length of patients at an American level 1 trauma center showed that a catheter length of 5 cm would reliably penetrate the pleural space in only 75% of patients.8  A 2008 study analyzing average chest wall thickness at the second intercostal space in the midclavicular line concluded that a 4.5-cm catheter length may not penetrate the chest wall in approximately 10-35% of trauma patients, depending on age and gender.9
  • Maintain a high index of suspicion for a tension pneumothorax in patients using ventilators who have a rapid onset of hemodynamic instability or cardiac arrest, particularly if they require increasing peak inspiratory pressures. Patients at greatest risk of a pneumothorax and/or tension pneumothorax include those with COPD who are using ventilators; those with acute respiratory distress syndrome; and those requiring a tidal volume greater than 12 mL/kg, a peak airway pressure greater than 60 cm H2 O, or a positive end-expiratory pressure greater than 15 cm H2 O.
  • Avoid assuming that a patient with a chest tube does not have a tension pneumothorax if he or she has respiratory or hemodynamic instability. Chest tubes can become plugged or malpositioned and cease to function. In addition, improper attachment of a one-way valve to the chest tube may produce tension pneumothorax.
  • A 2005 study of emergency physicians used a sampling of 25 emergency physicians, 21 of which had completed ATLS training. When attempting to correctly locate the needle thoracostomy site on a human volunteer, only 60% were able to correctly identify the second intercostal space, and all placed the thoracentesis needle medial to the midclavicular line. In this same study, 8% of participants inappropriately identified the site used for needle pericardiocentesis and 4% inappropriately identified the fifth intercostal space in the anterior axillary line.10
  • Related to the development of apparent life-threatening hemorrhage after decompression in the second intercostal space at the anterior, midclavicular line in patients with no initial evidence of hemothorax on presentation, it has been suggested that a potentially safer option is to decompress a pneumothorax in the fifth intercostal space at the anterior axillary line, similar to recommendations for chest drain insertion.
 


More on Pneumothorax, Tension and Traumatic

Overview: Pneumothorax, Tension and Traumatic
Differential Diagnoses & Workup: Pneumothorax, Tension and Traumatic
Treatment & Medication: Pneumothorax, Tension and Traumatic
Follow-up: Pneumothorax, Tension and Traumatic
Multimedia: Pneumothorax, Tension and Traumatic
References
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References

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Further Reading

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Contributor Information and Disclosures

Author

Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Disclosure: Nothing to disclose.

Medical Editor

Joseph A Salomone, III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine
Joseph A Salomone, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
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Managing Editor

Eric Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital, Manhattan
Eric Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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