Tension pneumothorax involves a pneumothorax with progressive accumulation of free air in the hemithorax that results in increased intrapleural pressure, with cardiorespiratory compromise. This can be a life-threatening condition that requires a high level of clinical suspicion and immediate intervention.


Patients at risk:

(1) trauma to the chest, blast injury

(2) after subclavian vein catheter insertion

(3) intermittent positive pressure ventilation in a patient with a simple pneumothorax


Clinical findings:

(1) dyspnea, tachypnea and respiratory distress

(2) distended neck veins, tachycardia, hypotension, unconsciousness and/or cardiac arrest

(3) deviation of the trachea, away from the affected side

(4) hyper-resonance to percussion over the affected hemithorax

(5) decreased to absent breath sounds over the affected hemithorax

(6) increase in inflation pressure for patients receiving intermittent positive pressure ventilation

(7) chest X-ray shows a pneumothorax with deviation of mediastinal structures away from the affected side


Management: This should not be delayed to wait for imaging studies.

(1) Start supplemental oxygen by facial mask.

(2) Insert a 16 gauge IV vascular catheter in the second intercostal space in the midclavicular line just above the third rib.

(3) If a tension pneumothorax is present, there should be an escape of gas through the catheter and there should be improvement in the patient's clinical findings.

(4) If a tension pneumothorax is demonstrated, insert a chest tube on the affected side.

(5) Obtain an upright chest X-ray to visualize tube placement and look for fluid accumulation.


Problematic areas:

(1) Bilateral tension pneumothorax may not result in tracheal deviation.

(2) The presence of hemothorax may reduce resonance over the affected hemithorax.


To read more or access our algorithms and calculators, please log in or register.