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 tension pneumothorax
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 extremist,
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
and it makes a very satisfying, whoosshhhh.
It's audible in the room,
the patient can hear it,
you can hear it,
everyone can hear it,
and you'll know at that point
that you have alleviated their tension pneumothorax.
In addition to needle decompression,
there are other elements of treatment that you wanna perform.
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 pressure ventilation
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 mechanically ventilated,
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 simple pneumothorax,
might be slightly hypoxic but typically it’s not extreme.
Tension pneumothorax causes shock
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 tension pneumothorax
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 tension pneumothorax
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 diagnosis clinically.
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.