Tension pneumothorax resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2], Mohamed Moubarak, M.D. [3], Twinkle Singh, M.B.B.S. [4], Rim Halaby, M.D. [5]

Tension Pneumothorax Resident Survival Guide Microchapters


Tension pneumothorax is a life threatening condition that results from the accumulation of air in the pleural cavity. Air enters the intrapleural space through an injured parietal pleura, visceral pleura or tracheobronchial tree that forms a one way valve. The one way valve allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, the intrapleural pressure rises and results in respiratory and cardiovascular failure. Tension pneumothorax can occur as a result of trauma, ventilation or resuscitation.[1] The cardinal symptoms and signs of tension pneumothorax are severe dyspnea, chest pain, hypotension, hypoxia, tachycardia and jugular vein distention. Tension pneumothorax should be managed immediately with emergency needle decompression followed by insertion of a chest tube.


Life Threatening Causes

Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) as shown below should be performed to identify patients in need of immediate intervention.

Boxes in red signify that an urgent management is needed.

Identify cardinal findings that increase the pretest probability of tension pneumothorax:
Chest pain
Jugular venous distension

❑ Absent breath sounds on the affected side
Hyperresonance on the affected side
❑ Hyperexpansion of the the affected side

Tracheal deviation towards the unaffected side[1]
Does the patient have high probability of tension pneumothorax?
❑ Immediately insert a 14-16 Gauge needle in the 2nd intercostal space at the midclavicular line of the affected hemithorax
❑ Insert chest drain immediately after needle decompression

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1]

Characterize the symptoms:

Chest pain
Altered mental status (in late stages)

Identify the precipitating factors:

❑ Recent invasive procedures

Central venous catheter
Pleural biopsy

Mechanical ventilation
Cardiopulmonary resuscitation
❑ Presence of chest drains
Hyperbaric oxygen treatment

Chest wall trauma
Examine the patient:

Appearance of the patient
Severe distress and labored respiration

Vital signs

Pulsus paradoxus




Jugular venous distension (absent in severe hypotension)

Respiratory examination

❑ Enlargement of the involved side of the chest
Intercostal space widening on the affected side
❑ Reduced lung expansion on the affected side
Tracheal deviation to the contralateral side
❑ Decreased vocal fremitus over the affected side
❑ Displacement of the apex beat
Hyperresonance over the affected side
❑ Diminished breath sounds on the affected side

Additional findings in ventilated patients

❑ Decreased oxygen saturation
❑ Increase in inflation pressure
❑ Increase in peak airway pressure

❑ Airway pressure alarm in mechanically ventilated patients
Consider alternative diagnosis:

Acute myocardial infarction

❑ Substernal chest discomfort, pain or tightness
❑ Radiation of chest pain to the left arm or jaw

Pericardial tamponade

Muffled heart sounds
Jugular vein distention
Pulsus paradoxus

Pulmonary embolism

❑ Presence of risk factors for pulmonary embolism
❑ Localized warmth, tenderness, edema and erythema in the leg suggestive of deep vein thrombosis
High probability of tension pneumothorax
Low probability of tension pneumothorax and patient is hemodynamically stable
❑ Proceed with immediate needle decompression
Order imaging studies:

❑ Order chest X-ray looking for:

❑ Air in the pleural cavity
❑ Contralateral deviation of trachea
❑ Increased thoracic volume
❑ Ipsilateral flattening of heart border
❑ Mid diaphragmatic depression

Shown below is an image of a chest X-ray depicting tension pneumothorax in the left lung.
Pneumothorax CXR.jpg
❑ Perform serial chest X-ray every 6 hours to rule out pneumothorax in cases of trauma[2]
❑ Order chest CT scan for uncertain or complex cases
Shown below is an image of CT scan depicting left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).
Pneumothorax CT.jpg

❑ Order ultrasonography in supine trauma patients among whom a chest X-ray can not be performed


Perform emergency needle decompression:[1]

❑ Wear a gown, face mask and eye shield
❑ Ensure aseptic preparation
❑ Determine the site of insertion of the needle

2nd intercostal space at the midclavicular line of affected hemithorax, OR
❑ 4th or 5th intercostal space on mid or anterior axillary line, if the initial decompression failed because of a thick chest wall[1]

❑ Insert a 14-16 gauge needle with a catheter at a 90° angle
❑ Remove the needle and leave the catheter in place
❑ Secure the catheter in place while preparing for tube thoracostomy (chest drain)
❑ Confirm the diagnosis by observing instantaneous escape of air as the needle is inserted
❑ Check for any improvement of the patient's status
Don't remove the catheter, until a chest drain is inserted and is functioning properly.

Shown below is a video depicting the steps for needle decompression

EmbedVideo was given an illegal value for the alignment parameter "How to do a needle decompression". Valid values are "left", "center", or "right".

Video adapted from Youtube.com

Insert a chest tube (tube thoracostomy) immediately after needle decompression:

❑ Make sure that the following equipments are available:

❑ 1% lidocaine
Iodine or chlorhexidine solution in alcohol
❑ Sterile drapes, gown, gloves
Needles, syringes, gauze swabs
Scalpel, suture (0 or 1-0 silk)
Chest tube kit
❑ Closed system drain (including water) and tubing
❑ Clamp

❑ Administer adequate analgesics
❑ Determine the insertion site at the anterior axillary line over the 4th or 5th rib
❑ Insert the chest drain
❑ Remove the catheter inserted during needle decompression after the confirmation that the chest drain is functioning properly
❑ Check chest tubes frequently, as they can become plugged or malpositioned

❑ Remove the chest tube after re-expansion of the affected lung is confirmed by a chest X-ray
Follow up:

❑ Refer the patient to a respiratory physician if pneumothorax does not respond within 48 hours
❑ Advise to return to the hospital if increasing breathlessness develops
❑ Advise to avoid air travel until the full resolution of the pneumothorax is confirmed by a chest X-ray
❑ Advise to avoid diving permanently unless the patient is treated with surgical pleurectomy



  • Suspect tension pneumothorax in the case of blunt and penetrating trauma to the chest.
  • Immediately cover penetrating chest wounds with an occlusive or pressure bandage in trauma patients with suspected tension pneumothorax.
  • Suspect tension pneumothorax among patients on mechanical ventilation who develop a rapid onset of hemodynamic instability or cardiac arrest and require an increase in the peak inspiratory pressure.
  • Order serial chest radiographs every 6 hours on the first day following chest trauma to rule out pneumothorax.[2]
  • Refer the patient to a respiratory specialist within 24 hours of admission.
  • Order a chest X-ray before chest tube removal to confirm the re-expansion of the affected lung.


  • Don't remove the catheter from the 2nd intercostal space unless a chest tube is appropriately placed.
  • Don't use large bore chest tubes.[1]
  • Don't leave the chest tube more than 7 days, as it will increase the risk of infection.


  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group (2010). "Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010". Thorax. 65 Suppl 2: ii18–31. doi:10.1136/thx.2010.136986. PMID 20696690.
  2. 2.0 2.1 Sharma A, Jindal P (2008). "Principles of diagnosis and management of traumatic pneumothorax". J Emerg Trauma Shock. 1 (1): 34–41. doi:10.4103/0974-2700.41789. PMC 2700561. PMID 19561940.

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