Tension pneumothorax- medical emergency

pathophysiology of a tension pneumothorax?

- air draw into pleural space with in each inspiration has no route of escape during expiration - mediastinum is pushed to contralateral hemithorax, kinking and compressing the great veins

symptoms?

- asymptomatic (especially in fit young people with small pneumothoraces) - can be sudden onset of dyspnoea and/or pleuritic chest pain - Patients with asthma or COPD may present with a sudden deterioration - Mechanically ventilated patients can suddenly develop hypoxia or an increase in ventilation pressures

If the patient is dyspneic/hypoxic and those with chronic lung disease?

- do an ABG

What should you do?

- requires immediate relief, do not delay management by obtaining a CXR

Causes?

- spontaneous: (especially in young thin men) due to rupture of a subpleural bulla - chronic lung disease: asthma, COPD, CF, lung fibrosis, sarcoidosis - infection: TB; pneumonia; lung abscess - traumatic: including iatrogenic (CVP line insertion, pleural aspiration or biopsy, percutaneous liver biopsy, positive pressure ventilation) - carcinoma - connective tissue disorders: Marfan's syndrome, Ehlers- Danlos syndrome

Signs?

- trachea deviated away from affected side - diminished breath sounds on affected side - reduced expansion - hyper resonance to percussion

Tests?

- CXR should not be done if a tension pneumothorax is suspected as it delays treatment

If the air isn't removed rapidly what will happen?

- Cardiorespiratory arrest

A pneumothorax due to trauma or mechanical ventilation requires what?

- Chest drain

when should surgical advice be arranged?

- If there are bilateral pneumothoraces - lung fails to expand after intercostal drain insertion - 2 or more previous pneumothoraces on the same side - or history of pneumothorax on the opposite side

What things does the management depend on?

- Whether it is a primary or secondary (underlying lung disease) pneumothorax, size and symptoms - see fig 1 on page 825