Tension pneumothorax

Although multiple definitions exist, a tension pneumothorax is generally considered to be present

when a pneumothorax leads to significant impairment of respiration and/or blood circulation.[4] The
most common findings in people with tension pneumothorax are chest pain and respiratory distress,
often with an increased heart rate (tachycardia) and rapid breathing (tachypnea) in the initial stages.
Other findings may include quieter breath sounds on one side of the chest, low oxygen levels and
blood pressure, and displacement of the windpipe away from the affected side. Rarely, there may be
cyanosis (bluish discoloration of the skin due to low oxygen levels), altered level of consciousness, a
hyperresonant percussion note on examination of the affected side with reduced expansion and
decreased movement, pain in the epigastrium (upper abdomen), displacement of the apex beat (heart
impulse), and resonant sound when tapping the sternum.[4] This is a medical emergency and may
require immediate treatment without further investigations (see below).[3][4]
Tension pneumothorax may also occur in someone who is receiving mechanical ventilation, in
which case it may be difficult to spot as the person is typically receiving sedation; it is often noted
because of a sudden deterioration in condition.[4] Recent studies have shown that the development of
tension features may not always be as rapid as previously thought. Deviation of the trachea to one
side and the presence of raised jugular venous pressure (distended neck veins) are not reliable as
clinical signs.

Tension pneumothorax
A tension pneumothorax is a life-threatening condition that develops when air is trapped in the
pleural cavity under positive pressure, displacing mediastinal structures and compromising
cardiopulmonary function. Prompt recognition of this condition is life saving, both outside the
hospital and in a modern ICU. Because tension pneumothorax occurs infrequently and has a
potentially devastating outcome, a high index of suspicion and knowledge of basic emergency
thoracic decompression procedures are important for all healthcare personnel. Immediate
decompression of the thorax is mandatory when tension pneumothorax is suspected. This should not
be delayed for radiographic confirmation. Note the image below.

This chest radiograph has 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.

Tension pneumothorax

Tension pneumothorax occurs anytime a disruption involves the visceral pleura, parietal pleura, or the tracheobronchial
tree. This condition develops when injured tissue forms a 1-way valve, allowing air inflow with inhalation into the
pleural space and prohibiting air outflow. The volume of this nonabsorbable intrapleural air increases with each
inspiration because of the 1-way valve effect. As a result, pressure rises within the affected hemithorax. In addition to
this mechanism, the positive pressure used with mechanical ventilation therapy can cause air trapping.
As the pressure increases, the ipsilateral lung collapses and causes hypoxia. Further pressure increases cause the
mediastinum to shift toward the contralateral side and impinge on and compress both the contralateral lung and impair
the venous return to the right atrium. Hypoxia results as the collapsed lung on the affected side and the compressed lung
on the contralateral side compromise effective gas exchange. This hypoxia and decreased venous return caused by
compression of the relatively thin walls of the atria impair cardiac function. Kinking of the inferior vena cava is thought
to be the initial event restricting blood to the heart. It is most evident in trauma patients who are hypovolemic with
reduced venous blood return to the heart.
Arising from numerous causes, this condition rapidly progresses to respiratory insufficiency, cardiovascular collapse,
and, ultimately, death if unrecognized and untreated.
Tension pneumothorax
The most common etiologies of tension pneumothorax are either iatrogenic or related to trauma, such as the following:

Blunt or penetrating trauma: Disruption of either the visceral or parietal pleura occurs and is often associated
with rib fractures, although rib fractures are not necessary for tension pneumothorax to occur.
Barotrauma secondary to positive-pressure ventilation, especially when using high amounts of positive endexpiratory pressure (PEEP)
Pneumoperitoneum[17, 18]
Fiberoptic bronchoscopy with closed-lung biopsy[19]
Markedly displaced thoracic spine fractures
Acupuncture[20, 21, 22]
Preexisting Bochdalek hernia with trauma[23]
Colonoscopy[24] and gastroscopy have been implicated in case reports.
Percutaneous tracheostomy[25]
Conversion of idiopathic, spontaneous, simple pneumothorax to tension pneumothorax
Unsuccessful attempts to convert an open pneumothorax to a simple pneumothorax in which the occlusive
dressing functions as a 1-way valve

Tension pneumothorax occurs commonly in the ICU setting in patients who are ventilated with positive pressure, and
practitioners must always consider this when changes in respiratory or hemodynamic status occur. Infants requiring
ventilatory assistance and those with meconium aspiration have a particularly high risk for tension pneumothorax.
Aspirated meconium may serve as a 1-way valve and produce a tension pneumothorax.
Any penetrating wound that produces an abnormal passageway for gas exchange into the pleural spaces and that results
in air trapping may produce a tension pneumothorax. Blunt trauma, with or without associated rib fractures, and
incidents such as unrestrained head-on motor vehicle accidents, falls, and altercations involving laterally directed blows
may also cause tension pneumothoraces.
Significant chest injuries carry an estimated 10-50% risk of associated pneumothorax; in about 50% of these cases, the
pneumothorax may not be seen on standard radiographs and are therefore deemed occult. In one study, 12% of patients
with asymptomatic chest stab wounds had a delayed pneumothorax or hemothorax. McPherson et al analyzed data from
the Vietnam Wound Data and Munitions Effectiveness Team study and determined that tension pneumothorax was the
cause of death in 3-4% of fatally wounded combat casualties. [26]

Acupuncture is a traditional Chinese medicine technique used worldwide by alternative medical practitioners.
Acupuncture's most frequently reported serious complication is pneumothorax; in one Japanese report of 55,291
acupuncture treatments, an approximate incidence of 1 pneumothorax in 5000 cases was documented. [27]
Iatrogenic and traumatic pneumothorax
Traumatic and tension pneumothoraces occur more frequently than spontaneous pneumothoraces, and the rate is
undoubtedly increasing in US hospitals as intensive care treatment modalities have become increasingly dependent on
positive-pressure ventilation, central venous catheter placement, and other causes that potentially induce iatrogenic
pneumothorax.
Tension pneumothorax
Tension pneumothorax is a complication in approximately 1-2% of the cases of idiopathic spontaneous pneumothorax.
Until the late 1800s, tuberculosis was a primary cause of pneumothorax development. A 1962 study showed a frequency
of pneumothorax of 1.4% in patients with tuberculosis.
The actual incidence of tension pneumothorax outside of a hospital setting is impossible to determine. Approximately
10-30% of patients transported to level-1 trauma centers in the United States receive prehospital decompressive needle
thoracostomies; however, not all of these patients actually have a true tension pneumothorax. Although this occurrence
rate may seem high, disregarding the diagnosis would probably result in unnecessary deaths. A review of military deaths
from thoracic trauma suggests that up to 5% of combat casualties with thoracic trauma have tension pneumothorax at the
time of death.[26]
The overall incidence of tension pneumothorax in the intensive care unit (ICU) is unknown. The medical literature
provides only glimpses of the frequency. In one report, of 2000 incidents reported to the Australian Incident Monitoring
Study (AIMS), 17 involved actual or suspected pneumothoraces, and 4 of those were diagnosed as tension
pneumothorax.