TENSION PNEUMOTHORAX

Recognition

Definition

• Pneumothorax is the “Accumulation of air in the pleural space” (BMJ best practice)
• A tension pneumothorax is a pneumothorax where air is able to enter the pleural cavity but is unable to leave. This results in an increase in the intrapleural pressure that can result in cardiac arrest

Typical clinical situations: (BTS guidelines 2010 Management of spontaneous pneumothorax)

• Following Cardiopulmonary resuscitation (CPR)
• Iatrogenic
• Lung disease
• Malfunctioning chest drains
• Trauma
• Ventilated patients

History

• If possible, ascertain if patient has:
  • Previous admissions with shortness of breath or respiratory conditions
  • Any operations or treatment for respirator conditions
  • Any allergies

General symptoms

• Shortness of breath (dyspnoea)
• Cyanosis
• Pleuritic pain

General Signs

• Tachypnoea
• Low Oxygen saturations
• Trachea deviated away from the affected side
• Use of accessory muscles for breathing
• Unilateral reduced chest expansion
• Unilateral decreased breath sounds
• Unilateral hyper-resonance to percussion
• Tachycardic
• Distended neck veins

Initial Assessment and Investigations

• ABCDE assessment
• Sit patient up if able to tolerate
• Assess patient’s airway
• Monitor oxygen saturations and respiratory rate
  • If patient is hypoxic give Oxygen (O₂) to achieve target saturations. Initially give 15 L/min via a reservoir mask if the patient is acutely unwell
• Target saturations:
  • 94 - 98% for patients not at risk of hypercapnic respiratory failure
  • 88 - 92% for patients at risk of hypercapnic respiratory failure due to conditions such as Chronic Obstructive Pulmonary Disease (COPD)
• Examine patient’s chest
  • Listen for:
    • Reduced or absent breath sounds
    • Hyper-resonance
• If you are considering the diagnosis of tension pneumothorax management is through immediate needle decompression (described in management)
• Call for senior help
• Arterial blood gas (ABG)
• Obtain intravenous access by placing 2 large bore cannulae in the antecubital fossa. Take blood to check Full Blood Count (FBC), Urea and Electrolytes (U&Es)
• Check Capillary Refill Time (CRT) - hold for five seconds and refilling should occur in 3 seconds
• Assess pulse rate, rhythm and character
• Monitor heart rate and blood pressure
• Listen to patients heart sounds
• Intravenous (IV) fluids as required by clinical picture and balanced with patients’ risk of fluid overload. See more details in the “Circulation” Chapter in the “Response” Section under “Fluid Challenge”
• Check pupils are equal and reactive
• Assess Glasgow Coma Scale or ACVPU using the NEWS2 chart
• Check patient’s temperature and blood sugar
• Examine patient’s abdomen and legs
• Consider venous thromboembolism prophylaxis

Response

Management

• Non-pharmacological management
  • Needle decompression (Advanced Trauma Life Support Student Course Manual Tenth Edition Published by American College of Surgeons guideline)
    • In larger adults use a large bore cannula in fourth or fifth intercostal space anterior to the midaxillary line
      • Leave in place and insert chest tube
    • In smaller adults or children place in the 2nd intercostal space mid-clavicular line
      • Leave in place and insert chest tube
    • Do not delay management by waiting for a chest X-ray

Referrals

• Discuss with senior member of the team
• Contact critical care outreach team
• Consider referral to Intensive Care Unit (ICU) if:
  • Patient requires ventilator support
  • Patient requires blood pressure support
  • Deterioration of blood gas following medical management

Future management

• Review by respiratory team regarding future management