So what are we gonna do to
treat a tension pneumothorax?
the first line of treatment
is needle decompression
and what we're doing when
we decompress the lung
is allowing air to get
out of the pleural space.
So if I've got a big high pressure
air collection here in my chest,
the goal of decompressing is to make a
conduit between the inside of my chest
and the outside world
that'll let that air escape.
And what's gonna happen,
is that's gonna equilibrate the pressure
inside of my pleural space
with the atmospheric pressure.
However, it's not gonna make
my pneumothorax go away,
it's not gonna actually restore
negative pleural pressure,
I'm still gonna
need a chest tube,
but it's going to decompress
the large air collection
that is mechanically interfering with my
cardiac function and my pulmonary function
and it's gonna improve the clinical
status of the patient very rapidly.
So I do wanna emphasize,
it's a temporizing measure,
it's not a definitive treatment.
What you're really doing
when you decompress
is you're taking a
and you're converting it
into a simple pneumothorax.
Needle decompression is also not
indicated for simple pneumothoraces
because it doesn't do
anything for those patients.
We only use it for unstable
patients with tension pneumothorax
and the goal is to restore their
normal perfusion and normal oxygenation
while we go about providing
them with definitive treatment.
So how do you do the procedure?
It's actually a very simple
and straight forward procedure
and it's incredibly
rewarding to perform
because patients go
from being an extremus,
to being stable and comfortable
and happy very, very quickly.
So if you get a
chance to do this,
I think you'll find it
to be very satisfying.
The way it works is you take
a 14 or 16 gauge angiocath
or basically any large
bore angiocath or needle
and you're gonna insert it at the second
intercostal space in the midclavicular line.
So you're gonna palpate
both sides of the clavicle,
you're gonna identify
the midclavicular line,
and then the second interspace is typically
is about one centimeter below that,
so that's what
you're gonna aim for.
You also can use the fourth or fifth
interspace in the anterior axillary line
if that anatomy is more favorable for
your patient, either one is acceptable.
So once you've inserted the needle,
this is the really important part,
you need to make sure that the
needle is open to room air.
So you wanna insert the needle
or angiocath in as far as it goes
and then you wanna to
take off your syringe,
take off your needle lock,
anything that might be obstructing
the end of your catheter
and you wanna let
the pleural space communicate
with the air in the room.
The goal again,
is to let air go from the pleura
out into the atmosphere
In addition to
there are other elements of
treatment that you wanna perform.
Of course, you wanna give these
patients supplemental oxygen
to help decrease their respiratory distress
and ensure that they're not hypoxic.
You want to avoid positive
until such time as you've
addressed the tension pneumothorax.
'Cause as you can imagine,
when we put a patient on
positive pressure ventilation,
we are actually pushing
air down into their lungs
and if they have an injury that's
led to a tension pneumothorax,
we're gonna be pushing air
out through that injury
into the pleural space and
expanding the pneumothorax
which is gonna make them worse.
So if your patient
needs to be intubated,
if they need to be
you should do that after you've
already addressed your pneumothorax.
You also wanna place a chest tube
once your patient is stabilized.
So you're gonna insert a
large caliber chest tube
on to the affected side
and that's what's gonna restore
your negative pleural pressure
and allow the lung to heal.
This is necessary in order to
allow the lung to fully reexpand
and eventually allow it
to seal off the defect
that caused the tension
pneumothorax in the first place.
So just a quick compare and contrast
between tension and simple pneumothorax
'cause it's really important to be
able to differentiate between them
since the treatment
is so different.
First and foremost, hypoxia.
Patients with tension pneumo
often have severe hypoxia.
Whereas patients with
might be slightly hypoxic but
typically it's not extreme.
because of the physiology
we've already described,
whereas simple pneumothorax
should never cause shock.
Simple pneumothorax does
not impair cardiac function.
It does not impair venous return and it
should have no hemodynamic consequences.
Breath sounds in
are almost, always gonna be completely
absent on the affected side.
Whereas in simple pneumothorax,
you might have
normal breath sounds,
you might have
reduced breath sounds.
If the pneumo is large,
you may even have absent breath sounds
but it's much more typical
to be able to hear something.
Whereas in a tension pneumo,
you can often hear nothing.
For tension pneumothorax,
we temporized the patient
with needle decompression.
So we're gonna go and stick
a needle in the affected side
to allow air to escape
from the pleural space.
Whereas in simple pneumothorax,
that procedure is not indicated
and really only carries
risk with no benefit,
so we would never do it.
Patients with tension pneumo always need
definitive treatment with a chest tube
and patients with simple
pneumothoraces often do as well.
It's quite common that we place
chest tubes in those patients.
But for small pneumothoraces,
sometimes, you can treat
with just high flow oxygen,
or in some cases,
you can use pleural drains,
pigtail catheters, etcetera,
as opposed to a large caliber chest tube.
So you've got a few more treatment options
available to you for simple pneumothorax.
With tension pneumo,
you're always gonna go for a chest tube.
So the bottom line on
is you should always suspect it
in patients with chest trauma,
who have unilaterally
absent breath sounds,
hypoxia, or severe respiratory
distress, or shock.
Those are the things that should
make you think about tension pneumo
and when you're concerned
about a tension pneumo,
you wanna make the
Once you've made the diagnosis,
you're gonna perform
a needle decompression
in order to temporize the patient
and then once they're stabilized,
you're gonna place a chest tube which
will serve as their definitive management.