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eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Pneumothorax, Tension and Traumatic


Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Updated: May 27, 2010

Introduction

Background
A pneumothorax refers to a collection of gas in the pleural space resulting in collapse of the lung
on the affected side. A tension pneumothorax is a life-threatening condition caused by air within
the pleural space that is under pressure; displacing mediastinal structures and compromising
cardiopulmonary function. A traumatic pneumothorax results from blunt or penetrating injury that
disrupts the parietal or visceral pleura. Mechanisms include injuries secondary to medical or
surgical procedures.

Pneumothorax is shown in the image below.


Pneumothorax, Tension and Traumatic.

Pathophysiology
A tension pneumothorax results from any lung parenchymal or bronchial injury that acts as a
one-way valve and allows free air to move into an intact pleural space but prevents the free exit
of that air. In addition to this mechanism, the positive pressure used with mechanical ventilation
therapy can cause air trapping.

As pressure within the intrapleural space increases, the heart and mediastinal structures are
pushed to the contralateral side. The mediastinum impinges on and compresses the
contralateral lung.

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. The
decrease in cardiac output results in hypotension and, ultimately, in hemodynamic collapse and
death to the patient, if untreated.

Frequency
United States

A study conducted from 1959-1978 involving a US community with an average of 60,000


residents reported an incidence of primary spontaneous pneumothorax of 7.4 cases per
100,000 persons per year for men and 1.2 cases per 100,000 persons per year for women.
When these figures are extrapolated, about 8,600 individuals develop primary spontaneous
pneumothorax in the United States per year.

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.

Undoubtedly, the incidence of pneumothorax and/or tension pneumothorax in US hospitals has


increased 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.

International

Acupuncture is a traditional Chinese medicine technique used worldwide by alternative medical


practitioners. Although generally considered to be a safe form of therapy, 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.[1 ]

Mortality/Morbidity
The clinician should assume that a tension pneumothorax results in hemodynamic instability
and death, unless immediately treated.

Sex
The male-to-female ratio is about 6:1 for primary spontaneous pneumothorax development.
 In men, the risk of spontaneous pneumothorax is 102 times higher in heavy smokers
than in nonsmokers. Spontaneous pneumothorax most frequently occurs in tall, thin men
aged 20-40 years.
 Catamenial pneumothorax is a rare phenomenon that generally occurs in women aged
30-50 years. It frequently begins 1-3 days after menses onset. Its etiology may be
primarily related to associated diaphragmatic defects.

Men undergoing treatment for tension pneumothorax are more likely to have a larger body
habitus with wider chest wall. Tension pneumothorax patients with wider chest walls undergoing
needle thoracostomy may need a catheter longer than 5 cm to reliably penetrate into the pleural
space.

Harcke et al using CT scan analysis of deployed male military personnel determined that, at the
second right intercostal space in the midclavicular line, the mean horizontal thickness was 5.36
cm, and that an 8-cm angiocatheter would reach the pleural space in 99% of the male soldiers
in this series.[2 ]

Age
Pneumothorax occurs in 1-2% of all neonates. The incidence of pneumothorax in infants with
neonatal respiratory distress syndrome is higher. In one study, 19% of such patients developed
a pneumothorax.

Clinical

History
The signs and symptoms produced by tension pneumothorax are usually more impressive than
those seen with a simple pneumothorax. Unlike the obvious patient presentations oftentimes
used in medical training courses to describe a tension pneumothorax, actual case reports
include descriptions of the diagnosis of the condition being missed or delayed because of subtle
presentations that do not always present with the classically described clinical findings of this
condition.

Symptoms and signs of tension pneumothorax may include the following:

 Chest pain (90%)


 Dyspnea (80%)
 Anxiety
 Acute epigastric pain (a rare finding)
 Fatigue

Physical
Findings at physical examination may include the following:

 Respiratory distress (considered a universal finding) or respiratory arrest


 Unilaterally decreased or absent lung sounds (a common finding; but decreased air
entry may be absent even in an advanced state of the disease)
 Adventitious lung sounds (crackles, wheeze; an ipsilateral finding)
 Lung sounds transmitted from the nonaffected hemithorax are minimal with auscultation
at the midaxillary line
 Tachypnea; bradypnea (as a preterminal event)
 Hyperresonance of the chest wall on percussion (a rare finding; may be absent even in
an advanced state of the disease)
 Hyperexpansion of the chest wall
 Increasing resistance to providing adequate ventilation assistance
 Cyanosis (a rare finding)
 Tachycardia (a common finding)
 Hypotension (should be considered as an inconsistently present finding; while
hypotension is typically considered as a key sign of a tension pneumothorax, studies
suggest that hypotension can be delayed until its appearance immediately precedes
cardiovascular collapse)
 Pulsus paradoxus
 Jugular venous distension
 Cardiac apical displacement (a rare finding)
 Tracheal deviation (an inconsistent finding; while historic emphasis has been placed on
tracheal deviation in the setting of tension pneumothorax, tracheal deviation is a
relatively late finding caused by midline shift)
 Mental status changes, including decreased alertness and/or consciousness (a rare
finding)
 Abdominal distension (from increased pressure in the thoracic cavity producing caudal
deviation of the diaphragm and from secondary pneumoperitoneum produced as air
dissects across the diaphragm through the pores of Kohn)
 When examining a patient for suspected tension pneumothorax, helpful indications of
subtle thoracic size and thoracic mobility differences may be elicited by performing
careful visual inspection along the line of the thorax. In a supine patient, by lowering
oneself to be in level with the patient.
 Tension pneumothorax may be a difficult diagnosis to make and may present with
considerable variability in signs presented. Respiratory distress and chest pain are
generally accepted as being universally present in tension pneumothorax. Tachycardia
and ipsilateral air entry are also common findings.
 The development of tension pneumothorax in patients who are ventilated will generally
be of faster onset with immediate, progressive arterial and mixed venous oxyhemoglobin
saturation decline and immediate decline in cardiac output.
 Cardiac arrest associated with asystole or pulseless electrical activity (PEA) may
ultimately result.

Causes
A wide variety of disease states and circumstances increase the patient's risk of a
pneumothorax. If a pneumothorax is complicated by a one-way valve effect, tension
pneumothorax may result.

 Infants requiring ventilatory assistance and those with meconium aspiration have a
particularly high risk for tension pneumothorax. Aspirated meconium may serve as a
one-way valve and produce a tension pneumothorax.
 Trauma may cause a pneumothorax.
o Tension pneumothorax may be the result of blunt trauma with or without
associated rib fractures.
o Incidents that may cause tension pneumothoraces include unrestrained head-on
motor vehicle accidents, falls, and altercations involving laterally directed blows.
o 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.
o Significant chest injuries carry an estimated 10-50% risk of associated
pneumothorax. In about half of these cases, the pneumothorax may be occult;
therefore, chest CT should always be performed.
o In one study, 12% of patients with asymptomatic chest stab wounds had a
delayed pneumothorax or hemothorax.
o McPherson et al, analyzing data from the Vietnam Wound Data and Munitions
Effectiveness Team study, determined that tension pneumothorax was the cause
of death in 3-4% of fatally wounded combat casualties.[3 ]
 Many procedures performed in an intensive care or emergency setting can result in an
iatrogenic pneumothorax and tension pneumothorax. Examples of these procedures
include incorrect chest tube insertion, mechanical ventilation therapy, central venous
cannulation; cardiopulmonary resuscitation; hyperbaric oxygen therapy; needle,
transbronchial, or transthoracic lung biopsy; liver biopsy or surgery; and neck surgery.
 Secondary or spontaneous tension pneumothorax is possible in many medical
conditions.
o Pneumothorax is associated with asthma, chronic obstructive pulmonary
disease, pneumonia (especially with Staphylococcus, Klebsiella,
Pseudomonas, and Pneumocystis species), pertussis, tuberculosis, lung
abscess, and cystic fibrosis.
o In pulmonary disorders such as asthma and emphysema, hyperexpansion
disrupts the alveoli.
o Increased pulmonary pressure due to coughing with a bronchial plug of mucus or
phlegm bronchial plug may play a role.
o Marfan syndrome is associated with an increased risk of pneumothorax.
o Individuals may inherit a predisposition for primary spontaneous pneumothorax.
o Although rare, spontaneous pneumothorax occurring bilaterally and progressing
to tension pneumothorax has been documented.

Differential Diagnoses
Acute Coronary Syndrome Pediatrics, Pneumonia
Acute Respiratory Distress Pericarditis and Cardiac Tamponade
Syndrome
Anxiety Pneumonia, Aspiration
Asthma Pneumonia, Bacterial
Congestive Heart Failure and Pneumonia, Empyema and Abscess
Pulmonary Edema
Diaphragmatic Injuries Pneumonia, Immunocompromised
Dissection, Aortic Pneumonia, Mycoplasma
Esophageal Perforation, Rupture Pneumonia, Viral
and Tears
Foreign Bodies, Trachea Pneumothorax, Iatrogenic, Spontaneous and
Pneumomediastinum
Myocardial Infarction Tuberculosis
Pediatrics, Pertussis
Other Problems to Be Considered
Airway obstruction
Hemothorax
Workup

Laboratory Studies
ABG analysis does not replace physical diagnosis nor should treatment be delayed while
awaiting results if symptomatic pneumothorax is suspected. However, ABG analysis may be
useful in evaluating hypoxia and hypercarbia and respiratory acidosis.

Imaging Studies

 Translumination: In neonatal patients, one may notice increased transmission of light


through the chest on the affected side.
 Chest radiography: Historical dogma has included the recommendation that a chest
radiograph of tension pneumothorax is a film that should never be taken. In addition, as
ultrasonography becomes increasingly available in emergency situations, the already
limited role of radiography will be even further minimized. Multiple recent studies have
shown bedside ultrasonography to be more accurate than supine chest radiography in
detecting and quantifying the presence of pneumothorax, including traumatic
pneumothorax. When considering radiography, utilizing a risk-benefit analysis has been
suggested, in which the time taken to obtain the radiograph is balanced against the
expected clinical course, with decompression preceding chest radiography in ventilated
patients who are prone to rapid decompensation.
o In a select subset of patients, it may be preferable to radiologically confirm and
localize tension pneumothorax before subjecting the patient to potential
morbidities arising from decompression. However, this consideration should be
limited to a subset of patients who are awake, stable, not in advanced stages of
tension and when an immediate chest film can be obtained, with a continuously
accompanying practitioner ready to perform urgent decompression should the
need arise.
o Although the initial chest radiograph may show no evidence of pneumothorax,
consider the possibility of delayed traumatic pneumothorax development in any
penetrating chest wound. Obtain serial chest radiographs every 6 hours the first
day after injury to rule this out. Some authors advocate the acquisition of only
one or two serial examinations every 4-6 hours.
o Air in the pleural cavity, with contralateral deviation of mediastinal structures, is
evidence of a tension pneumothorax. Tension pneumothorax chest radiographic
findings may include increased thoracic volume, increased rib separation, heart
border ipsilateral flattening, contralateral mediastinal deviation, and
hemidiaphragmatic depression.
o Pneumothorax chest radiograph findings include ipsilateral lung edge seen
parallel to the chest wall, increased lucency, and a deep sulcus sign (deep lateral
costophrenic angle).
o When evaluating the chest radiograph for pneumothorax, assess rotation.
Rotation can obscure a pneumothorax and mimic a mediastinal shift.
o In evaluating the radiograph for rotation, compare the symmetry and shape of the
clavicles. Also, look at the relative lengths of the ribs in the middle lung fields on
each side on the anteroposterior or posteroanterior views. On an image with
rotation, the ribs on each side often have unequal lengths.
o In a nonloculated pneumothorax, air rises to the nondependent portion of the
pleural cavity. Therefore, carefully examine the apices of an upright chest
radiograph, and scrutinize the costophrenic and cardiophrenic angles on a
supine chest radiograph.
o A skin fold can be mistaken for a pneumothorax. Unlike pneumothoraces, skin
folds usually continue beyond the chest wall, and lung markings can be seen
peripheral to the skin fold line. Viewing the film under the hot lamp may be
necessary to discern obscure peripheral lung markings.
o In evaluating the chest radiograph, first impressions of pneumothorax size can be
misleading. To assist in determining the size of pneumothorax on the radiograph,
a 2.5-cm margin of gas peripheral to the collapsing lung corresponds to a
pneumothorax of about 30%. Complete collapse of the lung is a 100%
pneumothorax.
 Chest CT scanning
o Collapse of the lung, air in the pleural cavity, and deviation of mediastinal
structures are present in tension pneumothorax.
o A CT scan is more sensitive than a chest radiograph in the evaluation of small
pneumothoraces and pneumomediastinum, although the clinical significance of
these occult pneumothoraces is unclear, particularly in the stable nonintubated
patient.
o A CT scan may allow for further evaluation of underlying pulmonary disease or
injury.
 Ultrasonography
o Use of bedside ultrasonography in the diagnosis of pneumothorax is a relatively
recent development. In some trauma centers, pneumothorax detection is
included as part of their focused abdominal sonography for trauma (FAST)
examination. Knudtson et al, in a prospective analysis of 328 consecutive trauma
patients at a level 1 trauma center, obtained a specificity of 99.7% and an
accuracy of 99.4%, and concluded that ultrasonography was a reliable modality
for the diagnosis of pneumothorax in the injured patient.[4 ]
o Ultrasonographic features used in the diagnosis of pneumothorax include
absence of lung sliding (high sensitivity and specificity), absence of comet-tail
artifact (high sensitivity, lower specificity), and presence of lung point (high
specificity, lower sensitivity). In the absence of pleural disease, visceral pleura
moves against parietal pleura while breathing. This movement of the two pleura
is detected by the ultrasound as lung sliding, which is a "kind of twinkling
synchronized with respiration" seen in real-time and time-motion modes. Comet-
tail artifacts are vertical air artifacts that arise from the visceral pleural line (or in
the case of parietal emphysema or shotgun pellets may arise above the pleural
line).
o Lung point, the location that lung-sliding and absent lung-sliding alternately
appear, has been shown in multiple studies to allow determination of the size of a
pneumothorax. Zhang et al obtained a 79% sensitivity in lung point's ability to
determine pneumothorax size.[5 ]
o In one study, ultrasonography had 95.5% sensitivity and 100% specificity for
pneumothorax detection compared with chest radiography. In another study,
ultrasonography performed on patients with blunt thoracic trauma had 94%
sensitivity and 100% specificity for pneumothorax detection compared with spiral
CT scanning. A prospective study involving 135 patients with multiple trauma
using bedside ultrasonography performed by emergency department clinicians
obtained 86% sensitivity and 97% specificity for the detection of pneumothorax.
o A prospective study by Brook et al was designed to assess the accuracy of
radiology residents in detecting pneumothoraces as part of the extended focused
assessment with sonography for trauma (eFAST). Comparing sonographic
pneumothorax detection (by the absence of parietal-over-visceral lung sliding
with "comet tail" artifacts behind it) with the reference standard of chest CT in
169 consecutive trauma patients (ie, 338 lung fields) demonstrated a sensitivity
of 47%, specificity of 99%, positive predictive value of 87%, and negative
predictive value of 93%; with none of the small pneumothoraces missed by
ultrasound requiring drainage during the hospitalization period. The authors
concluded that sonographic pneumothorax detection by these radiology residents
was both accurate and efficient in the early detection of clinically important
pneumothoraces.[6 ]

Procedures
 Needle thoracostomy is performed as follows:
o Locate puncture site. The second intercostal space in the midclavicular line on
the affected side immediately superior to the rib is most commonly recommended
site.
o Prepare the puncture site with povidone-iodine (Betadine), alcohol scrubs, or
both.
o Insert a large-bore Angiocath (14-gauge in an adult, 18- or 20-gauge in an infant)
into the desired intercostal space over the top of the rib and perpendicular to the
chest wall. Listen for a rush of air.
o Remove the needle.
o Secure the Angiocath in place, and establish a water seal or flutter valve.
o Immediately prepare to insert a chest tube.
o Listen for a rush of air on insertion to confirm the diagnosis of tension
pneumothorax. Note this finding on the patient's chart. In an area with high
ambient noise, the escape of air may not be detected.
o Needle thoracostomy requires follow-up placement of a chest tube.
o Potential morbidity associated with needle thoracostomy includes pneumothorax
(with potential to tension later), cardiac tamponade, hemorrhage (which can be
life-threatening), loculated intrapleural hematoma, atelectasis, pneumonia,
arterial air embolism (when needle thoracostomy is performed and no tension
pneumothorax is present), and pain to the patient.
 Tube thoracostomy is performed as follows:
o If the patient is hemodynamically stable, consider conscious sedation with careful
titration of a short-acting narcotic and benzodiazepine. However, use of a local
anesthetic often is adequate.
o Place the patient in a 30-60° reverse Trendelenburg position, scrub the site with
povidone-iodine (Betadine), alcohol, or both, and anesthetize the site with
lidocaine.
o Make a 3- to 4-cm incision over the fifth or sixth rib in the midaxillary line.
o Use a curved hemostat to puncture the intercostal muscles and parietal pleura
immediately superior to the rib border, avoiding damage to the underlying lung.
Then, slide a finger over the clamp to maintain the formed tract.
o Perform a digital examination to assess the location and to evaluate pulmonary
adhesions. Sweep the finger in all directions, and feel for the diaphragm and
possible intra-abdominal structures. To avoid losing the desired tract, keep the
finger in place until the tube is inserted.
o Insert the chest tube along side of the finger, using a clamp on the tube, if
desired.
o Direct the chest tube posteriorly and inferiorly, and insert it until it is at least 5 cm
beyond the last hole of the tube.
o Attach the tube to a water seal and vacuum device (eg, Pleur-Evac). Look for
respiratory variation and bubbling of air through the water seal. Document the
amount of blood or other fluids that may drain.
o Suture the site, and secure the tube. A variety of anchoring and closure
techniques exist, all of which are probably equivalent. Cover the site with
petroleum jelly–impregnated gauze, and apply a suitable dressing.
o Follow-up chest radiography is required to confirm tube placement and lung
reexpansion.
o Complications of tube thoracostomy include death, injury to lung or mediastinum,
hemorrhage (usually from intercostal artery injury), neurovascular bundle injury,
infection, bronchopleural fistula, and subcutaneous or intraperitoneal tube
placement.

Treatment

Prehospital Care
Attention to the ABCs is mandatory for all patients with thoracic trauma. Evaluate the patency of
the airway and the adequacy of the ventilatory effort. Assess the circulatory status and the
integrity of the chest wall.

 Failure of the emergency medical service personnel and medical control physician to
make a correct diagnosis of tension pneumothorax and to promptly perform needle
decompression in the prehospital setting can result in rapid clinical deterioration and
cardiac arrest.
 However, if an incorrect diagnosis of tension pneumothorax is made in the prehospital
setting, the patient's life is endangered by unnecessary invasive procedures. Close
cooperation and accurate communication between the emergency department and the
emergency medical service personnel is of paramount importance.
 To prevent reentry of air into the pleural cavity after needle thoracostomy and
decompression in the prehospital setting, a one-way valve should be attached to the
distal end of the Angiocath. If available, a Heimlich valve may be used. If a commercially
prepared valve is not available, attach a finger condom or the finger of a rubber glove
with its tip removed to serve as a makeshift one-way valve device.
 Clothing covering a wound that communicates with the chest cavity can play a role in
producing a one-way valve effect, allowing air to enter the pleural cavity but hindering its
exit. Removing such clothing items from the wound may facilitate decompression of a
tension pneumothorax.
 A tension pneumothorax is a contraindication to the use of military antishock trousers.

In a preliminary 2006 study from Norway, Busch evaluated the feasibility of using portable
ultrasound in an air rescue setting.[7 ]Concluding that prehospital ultrasonography could provide
diagnostic and therapeutic benefit when conducted by a proficient examiner who used goal-
directed and time-sensitive protocols. Further study in this area may help to determine the
indications and role of prehospital sonography.

Emergency Department Care


For all patients with thoracic injury, immediate and careful attention to the ABCs is vital. Fully
assess the patency of the airway and adequacy of the ventilatory effort. Carefully evaluate the
cardiovascular system because a tension pneumothorax and a pericardial tamponade can
cause similar findings.

 If a tension pneumothorax is suspected, immediately administer 100% oxygen, and


evaluate the patient for evidence of respiratory compromise, hemodynamic instability, or
clinical deterioration. Place large-bore catheters, because hemothorax can be
associated with pneumothorax, and the patient may, therefore, require immediate
intravenous infusion. Upright positioning, if not inappropriate due to cervical spine or
trauma concerns, may be beneficial.
 Immediately perform needle thoracostomy or chest tube placement (see Procedures) if
the clinical condition warrants such action. Once a needle thoracostomy has been
performed, chest tube insertion must follow.
 If a hemothorax is associated with the pneumothorax, additional chest tubes may be
needed to assist drainage of blood and clots. If the hemopneumothorax requires
insertion of a second chest tube, the second tube should be directed inferiorly and
should be posterior to the diaphragm.
 Chest tubes are attached to a vacuum apparatus that continually removes air from the
pleural cavity. The collapsed lung reexpands and heals, thereby preventing continued air
leakage. After air leaks have ceased for 24 hours, the vacuum may be decreased and
the chest tube removed.
 The process of lung reexpansion and healing is not immediate and may be complicated
by pulmonary edema; therefore, a chest tube is usually left in place for at least 3 days
unless the clinical condition warrants a longer placement.
 In general, traumatic pneumothoraces should be treated with insertion of a chest tube,
particularly if the patient cannot be closely observed. A subset of patients who have a
small (<15-20%), minimally symptomatic pneumothorax may be admitted, observed
closely, and monitored by using serial chest radiographs. In these patients,
administration of 100% oxygen promotes resolution by speeding the absorption of gas
from the pleural cavity into the pulmonary vasculature.

Hernandez et al noted that ultrasonography is the only radiographic modality allowing patients
with nonarrhythmogenic cardiac arrest to continue undergoing resuscitation while searching for
easily reversible causes of asystole or PEA.[8 ]Their proposal is for further investigation into a
protocol (using the acronym C.A.U.S.E. for cardiac arrest ultrasound exam) in which cardiac
arrest patients, concurrent with resuscitation, receive bedside ultrasonography to look for
cardiac tamponade, massive pulmonary embolus, severe hypovolemia, and tension
pneumothorax. Their hope is that the eventual adoption of ultrasonography in this setting may
allow increased "real-time" diagnostic acumen, decreasing the time required to receive
appropriate condition-related therapy.

Consultations

 Treatment of tension pneumothorax should commence immediately after diagnosis,


without waiting for further consultation and/or evaluation.
 A trauma or general surgeon should evaluate patients with trauma, and the patient
should be admitted for observation.

Medication

A tension pneumothorax requires treatment with procedural modalities. Anesthetics and


analgesics should be used if the patient is not in distress. Medication may be necessary to treat
the pulmonary disorder that caused the pneumothorax. For example, intravenous antibiotics are
included in the treatment of a pneumothorax that developed as a sequela of staphylococcal
pneumonia. Also, studies suggest that the administration of prophylactic antibiotics after chest
tube insertion may reduce the incidence of complications such as emphysema.

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.[9 ]

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
Complications of tension or traumatic pneumothorax may include the following:

 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.[10 ]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.[11 ]
 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.[12 ]
 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.

Multimedia
Media file 1: Pneumothorax, Tension and Traumatic.
Media file 2: Pneumothorax, Tension and Traumatic.
Media file 3: Pneumothorax, Tension and Traumatic.
Media file 4: Pneumothorax, Tension and Traumatic.
Media file 5: Pneumothorax, Tension and Traumatic.
Media file 6: Pneumothorax, Tension and Traumatic.
Media file 7: Subcutaneous emphysema and pneumothorax.

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Keywords

pneumothorax, tension pneumothorax, traumatic pneumothorax, pleural gas, idiopathic


spontaneous pneumothorax, tuberculosis, iatrogenic pneumothorax, catamenial pneumothorax,
respiratory distress, cyanosis, chest trauma, penetrating wound

chest stab wounds, mechanical ventilation therapy, central venous cannulation,


cardiopulmonary resuscitation, hyperbaric oxygen therapy, transbronchial lung biopsy,
transthoracic lung biopsy, liver biopsy, liver surgery, neck surgery, asthma, chronic obstructive
pulmonary disease, Staphylococcus pneumonia, Klebsiella pneumonia, Pseudomonas
pneumonia, Pneumocystis pneumonia, pertussis, lung abscess, cystic fibrosis, emphysema,
Marfan syndrome

Contributor Information and Disclosures

Author

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

Medical Editor

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Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas
City, Missouri
Joseph A Salomone III, MD is a member of the following medical societies: American Academy
of Emergency Medicine, National Association of EMS Physicians, and Society for Academic
Emergency Medicine
Disclosure: Nothing to disclose.
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Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine


Disclosure: eMedicine Salary Employment

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Eric L Legome, MD, Chief, Department of Emergency Medicine, Kings County Hospital Center;
Associate Professor, Department of Emergency Medicine, New York Medical College
Eric L 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
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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
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Deaconess Medical Center
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American Academy of Emergency Medicine, American College of Emergency Physicians,
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