TENSION PNEUMOTHORAX

A tension pneumothorax is present when the intrapleural pressure exceeds the atmospheric
pressure throughout expiration and often during inspiration as well.[1] Most patients who develop
a tension pneumothorax are receiving positive pressure to their airways, either during mechanical
ventilation or during resuscitation.[1] For a tension pneumothorax to develop in a spontaneously
breathing person, some type of one-way valve mechanism must be present so more air enters the
pleural space on inspiration than leaves the pleural space on expiration, so air accumulates in the
pleural space under positive pressure.[1]

Pathophysiology
The development of a tension pneumothorax is usually heralded by a sudden deterioration in the
cardiopulmonary status of the patient. The explanation for this sudden deterioration is probably
related to the combination of a decreased cardiac output due to impaired venous return and
profound hypoxia due to ventilation-perfusion mismatches. In mechanically ventilated sheep, an
induced tension pneumothorax (mean pleural pressure of +25 cm H2O) reduced the cardiac
output from 3.5 to 1.1 L/min.[78] The arterial PO2 also fell from a baseline value of 159 to
59 mm Hg. Comparable reductions in cardiac output and oxygen saturation were seen in pigs[79]
and in dogs[80] following induction of tension pneumothoraces. Similarly, in patients on
mechanical ventilation who develop tension pneumothorax, there is a large drop in the cardiac
output.[81]

Clinical Manifestations
Patients most commonly have a tension pneumothorax while they are receiving positive-pressure
mechanical ventilation, during cardiopulmonary resuscitation,[82] or as a complication of
hyperbaric oxygen therapy.[1] Occasionally, a tension pneumothorax will evolve during the
course of a spontaneous pneumothorax. Tension pneumothorax can develop from improper
connection of one-way flutter valves with small-caliber chest tubes.[83]

The clinical picture associated with the development of a tension pneumothorax is striking. The
patient appears distressed, with rapid labored respirations, cyanosis, marked tachycardia, and
profuse diaphoresis. The physical findings are those of a very large pneumothorax. Arterial
blood gases reveal marked hypoxemia and sometimes respiratory acidosis.

Tension pneumothorax should be suspected in patients receiving mechanical ventilation who

suddenly deteriorate. In this situation, the peak pressures on the ventilator usually increase
markedly if the patient is on volume-type ventilation, whereas the tidal volumes decrease
markedly if the patient is on pressure-support ventilation.[1] Tension pneumothorax should also
be suspected in any patient undergoing cardiopulmonary resuscitation in whom ventilation
becomes difficult. In one series of 3500 autopsies, an unsuspected tension pneumothorax was
found in 12 cadavers; 10 of these had received mechanical ventilation, and 9 had undergone
cardiopulmonary resuscitation.[84] Tension pneumothorax should also be suspected in patients
with a known pneumothorax who deteriorate suddenly or in patients who have undergone a
procedure known to cause a pneumothorax.

Diagnosis and Treatment

A tension pneumothorax is a medical emergency. One should not waste time trying to establish
the diagnosis of tension pneumothorax radiologically because the clinical situation and the
physical findings usually strongly suggest the diagnosis.[1] The patient should immediately be
given high-flow supplemental oxygen to alleviate the hypoxia. Once the abnormal hemithorax is
identified, a large-bore (14- to 16-gauge) catheter with needle should be immediately inserted
into the pleural space through the second anterior intercostal space.[1] After the catheter and
needle are inserted into the chest, the needle is removed and a large syringe containing a few
milliliters of sterile saline is attached to the indwelling catheter. The plunger is then pulled out of
the syringe. If air bubbles through the saline after withdrawing the plunger, the diagnosis of
tension pneumothorax is established. If the fluid enters the pleural space from the syringe, the
patient does not have a tension pneumothorax and the catheter should be removed.

If the procedure just described confirms the diagnosis of a tension pneumothorax, the catheter
should be left in place and in communication with the atmosphere until air ceases to exit through
the syringe. Additional air can be withdrawn from the pleural space with the syringe and the
three-way stopcock. The patient should be prepared for immediate tube thoracostomy