Management of Pneumothorax and Tension Pneumothorax

Tension Pneumothorax Recognition and Emergency Management

Tension pneumothorax presents with rapid labored respiration, cyanosis, sweating, tachycardia, and progressive respiratory distress, particularly in patients on mechanical ventilation or non-invasive ventilation who suddenly deteriorate or develop pulseless electrical activity (PEA) 1, 2
Immediate needle decompression using a cannula of at least 4.5 cm length (preferably 7 cm) should be performed in the second intercostal space in the mid-clavicular line, followed by chest tube insertion 1
Leave the decompression cannula in place until a functioning intercostal tube can be positioned, and confirm proper function by observing bubbling in the underwater seal system 1, 2

After needle decompression in tension pneumothorax, or as primary treatment for significant pneumothorax, insert a chest tube, with a small gauge drain usually adequate for standard pneumothorax 3, 4
Insertion steps include administering adequate local anesthesia, positioning the tube in the appropriate intercostal space (usually 4th-5th intercostal space, mid-axillary line), and connecting to an underwater seal drainage system 1

Most clinicians attach drains to an underwater seal system, with the Heimlich one-way flutter valve as an alternative for outpatient management 3
Monitor for air leak persistence, proper tube position, adequate drainage, and complications including infection or tube displacement 1

For patients with cystic fibrosis or severe underlying lung disease, pneumothorax may require longer management and has higher recurrence rates, and consider surgical options (pleurectomy, pleural abrasion) for recurrent pneumothoraces 1, 2
Patients on positive pressure ventilation who develop pneumothorax should always receive tube thoracostomy, and patients should not travel by air within 6 weeks of thoracic surgery or resolution of a spontaneous pneumothorax 1, 3