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