All types of pneumothorax have the potential to become a tension pneumothorax, which is life-threatening and must be recognised and treated in a timely manner. A tension pneumothorax is one of the 4Hs and 4Ts of reversible cardiac arrest. You can read more about the 4Hs and 4Ts here.
This guide gives an overview of the recognition and immediate management of pneumothorax using the ABCDE approach. You can check out our overview of the ABCDE approach here.
A pneumothorax is a collection of air between the parietal and visceral pleura.
There are several different ways to classify and name pneumothoraces.
A primary pneumothorax occurs without any underlying disease.
A secondary pneumothorax is due to underlying lung disease such as asthma or COPD.
Pneumothoraces can also be described as either spontaneous or traumatic (e.g. occurring secondary to penetrating chest trauma).
All types of pneumothorax can potentially develop into a tension pneumothorax.
A tension pneumothorax is life-threatening because it results in a sudden rise in intrathoracic pressure which reduces venous return to the heart and ultimately causes cardiac arrest.
You are likely to be called to see this patient as a new presentation to ED with chest pain and/or shortness of breath.
If you think your patient has a compromised airway you need help.
Put out a crash call immediately as you require urgent anaesthetic input to secure the airway.
You can perform some simple airway manoeuvres in the meantime.
A tension pneumothorax is a clinical diagnosis.
An arterial blood gas may be useful to quantify the degree of hypoxia if your patient has low oxygen saturations.
ABG results in pneumothorax may show low PaO2 and normal/low PaCO2 due to hyperventilation.
Small pneumothoraxes can be difficult to see on the CXR, especially if you aren't looking for them!
A chest x-ray showing a tension pneumothorax should ideally never be seen, as it should have been identified during clinical examination and treated immediately.
If, however, a chest x-ray was performed, you would expect to see visible tracheal deviation and lung collapse.
There are very clear guidelines from the British Thoracic Society (BTS) on how to treat a pneumothorax.
The BTS guidelines for a simple pneumothorax (not tension) can be found in full here, but the key management options are summarised below.
Tension pneumothorax requires immediate treatment.
The definitive treatment will be a chest drain insertion, however, as this can take a couple of minutes to arrange and set up, a needle decompression is indicated initially.
If you think you are dealing with a tension pneumothorax you will need help ASAP.
This scenario would warrant putting out a peri-arrest call on 2222.
Needle decompression involves placing a needle or cannula into the 2nd intercostal space, mid-clavicular line (on the affected side) to immediately relieve some tension.
After this has been done you can proceed to chest drain insertion.
This should not delay your management of the pneumothorax.
We routinely expose all unwell patients to make sure that we aren't missing anything.
A fever might indicate an underlying infection (e.g. pneumonia).
If possible, it is important to revisit history taking to clarify risk factors for pneumothorax (e.g. trauma or underlying respiratory conditions) and other relevant medical information. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate. Check out the history taking guides here.
It is really important that you document your initial ABCDE findings, any interventions you made and the response the patient had to those interventions. Also, make sure to document salient points from the history.
You need to discuss the patient with the medical team. If your patient requires a higher level of care (HDU/ICU) then you need to speak to the appropriate teams directly.
Does the patient need further treatment?
For example, will the patient need a repeat CXR to check chest drain position or to see if aspiration has been successful in treating the pneumothorax?
Should they be referred for a review by a specialist doctor (e.g. a respiratory physician)?