ITCB: Tension Pneumothorax
Summary Definition: Tension pneumothorax is a life-threatening condition involving a progressive accumulation of air in the pleural space. Damage to the parietal, visceral, or mediastinal pleura may result in a one-way valve injury where air enters the pleural space on inhalation without leaving on exhalation (Leigh-Smith and Harris, 2005). The increased positive pressure within the pleural cavity compresses the lung, diaphragm, pulmonary vessels, vena cava, and mediastinum, which results in respiratory and/or hemodynamic compromise (Barton, 1999; Savage, 2011). Recognizing a Tension Pneumothorax: Scenarios resulting in a tension pneumothorax can include trauma (penetrating or blunt), positive pressure ventilation, pulmonary/thoracic procedures (ex. chest drain insertion, central venous line placement), and spontaneous pneumothorax (Holloway and Harris, 2000). The clinical signs can be variable and inconsistent; therefore, the diagnosis is often based on suspicion and consideration of the mechanism of injury (Lee, Revell, Porter and Steyn, 2007; Leigh-Smith and Harris, 2005). Signs and symptoms may include: - Respiratory distress - Pleuritic chest pain - Dyspnea - Jugular venous distention - Tachypnea - Absent unilateral breath sounds (pneumothorax side) - Tachycardia - Contralateral tracheal deviation (away from pneumothorax) - Hypoxia - Hypotension (indicates obstructive shock) (Leigh-Smith and Harris, 2005; Rutherford, Hurt, Brickman and Tubb, 1968; Savage, 2011). Do not wait for diagnostic confirmation from imaging before performing needle decompression. Confirmation should only be obtained before treatment in patients that are stable and the diagnosis is uncertain (Savage, 2011; Alrajab, Youssef, Akkus and Caldito, 2013). Treatment: According to Kirsch and Sax (2014), treatment involves application of high-flow oxygen, supine positioning of the patient, skin preparation with chlorhexidine or povidone-iodine, universal precautions and emergent needle decompression (needle thoracostomy) to release the rising intrapleural pressure. Supine positioning helps avoid lung injury by allowing air to rise to the anterior thoracic cavity and the collapsing lung to be displaced posteriorly. Clinical guidelines, including the Advanced Trauma Life Support (ATLS) suggest a 14-gauge angiocatheter needle that is at least 4.5cm in length is placed in one of two anatomic locations: the 2nd intercostal space (ICS), midclavicular line (MCL) or the 5th ICS, just anterior to the midaxillary line (MAL). The length of catheter and anatomic location have been controversial in the literature in recent years, and a summary of the recent literature can in the next section, below. A syringe filled with sterile saline attached to the cannula may help confirm pleural penetration; as well, an Asherman chest seal can help to stabilize the cannula preventing displacement or kinking (Leigh-Smith and Harris, 2005). After insertion, the needle is removed, leaving the cannula in place. Following needle decompression, the pneumothorax must be treated with a tube thoracostomy (chest tube insertion) in the 4th or 5th ICS-MAL (Kirsch and Sax, 2014). Remember that the 2nd rib is found at the sternomanubrial joint between the manubrium and sternum. The catheter should be inserted just superior to the third rib to avoid the neurovascular bundle which is inferior to each rib (Kirsch and Sax, 2014).
Ryan Wilke (2015), Sean Crooks (2016)
ITCB: Tension Pneumothorax
Needle/ Catheter Controversy: Due to increasing prevalence of obesity in Western populations, the optimal needle length and anatomical site of decompression is controversial: Hecker at al. (2016) recommended a needle of length of 7 cm to decompress a tension pneumothorax in the 2nd ICS-MCL to successfully decompress more than 90% of the 2574 participants in this study. Clemency et al. (2015) found in their meta-analysis that a catheter of at least 6.44cm in length would be needed to decompress 95% of patients. This study measured the chest wall thickness again at the 2nd ICSMCL to determine this. Wax and Leibowitz (2007) found that needles as long as 7 cm (2 ¾ inch) may be required at the 2nd ICSMCL in patients with larger pectoral muscles and subcutaneous tissue. Ball et al. (2010) found that a 4.5 cm (1 ¾ inch) long catheter-over-needle should reach the pleural space in 96% of adults for the 2nd ICS-MCL needle decompression. Anatomic Location Controversy: Chan et al, 2014 found chest wall thickness was significantly thinner at the 5th intercostal space (ICS), anterior axillary line (AAL) (3.8-4.0cm), than 2nd ICS-MCL (4.3-4.7cm). Laan et al. (2015) found that the 4th/5th ICS-AAL has the lowest predicted rate of failed needle decompression. They also found a needle length of 4.0cm would be needed to decompress 95% of patients at 4th ICS-AAL. There is no data to suggest a difference in risk to the patient between the 2nd ICS-MCL and the 4th/5th ICSAAL (Netto et al. 2008; Wernick et al, 2016). Controversy Summary: The use of the anatomic site of 2nd ICS-MCL or the 4th/5th ICS-AAL to perform needle decompression are both acceptable and based on clinician judgment and preference. If decompressing at the 2nd ICS-MCL, longer needles than recommended 5cm up to 7 cm may be required for successfully decompression. The studies all recognized the risk of using a longer catheter for decompression may lead to higher risk of injury to vital structures and hemothorax. A 5cm needle (4.5cm catheter) used in the 4th/5th (ICS-AAL) instead of the currently stated 2nd ICS-MCL may lead to the highest rate of successful decompression. Care must be taken if patient is in transport to not dislodge the catheter from this location.
Ryan Wilke (2015), Sean Crooks (2016)
ITCB: Tension Pneumothorax
Reference List American College of Surgeons. Committee on Trauma. Advanced Trauma Life Support Program for Doctors Manual, 6th ed. Chicago , IL : American College of Surgeons, 1997, p 189. Alrajab, S., Youssef, A.M., Akkus, N.I., Caldito, G. (2013). Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis. Journal of Critical Care, 17(5): 208. doi: 10.1186/cc13016. Ball, C.G., Wyrzykowski, A.D., Kirkpatrick, A.W., Dente, C.J., Nicholas, J.M., Salomone, J.P., . . . Feliciano, D.V. (2010). Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Canadian Journal of Surgery, 53(3): 184-8 Barton, E.D. (1999). Tension pneumothorax. Current Opinion in Pulmonary Medicine, 5(4):269-74 Chang, S. J., Ross, S. W., Kiefer, D. J., Anderson, W. E., Rogers, A. T., Sing, R. F., & Callaway, D. W. (2014). Evaluation of 8.0-cm needle at the fourth anterior axillary line for needle chest decompression of tension pneumothorax. Journal of Trauma and Acute Care Surgery, 76(4), 1029-1034. Clemency, B.M., Tanski, C.T., Rosenberg, M., May, P.R., Consiglio, J.D., Lindstrom, H.A. (2015). Sufficient Catheter Length for Pneumothorax Needle Decompression: A Meta-Analysis Prehospital and Disaster Medicine, 30(3): 249-253. Hecker, M., Hegenscheid, K., Völzke, H., Hinz, P., Lange, J., Ekkernkamp, A., & Frank, M. (2016). Needle decompression of tension pneumothorax: Population-based epidemiologic approach to adequate needle length in healthy volunteers in Northeast Germany. Journal of Trauma and Acute Care Surgery, 80(1), 119-124.
Holloway, V.J. & Harris, J.K. (2000). Spontaneous pneumothorax: is it under tension? Journal of Accident & Emergency Medicine, 17(3): 222-3. Kirsch, T.D. & Sax, J. 2014. Tube Thoracostomy. Roberts and Hedges’ Clinical Procedures in Emergency Medicine, Chapter 10, 189-211.e1 Laan, D. V., Vu, T. D. N., Thiels, C. A., Pandian, T. K., Schiller, H. J., Murad, M. H., & Aho, J. M. (2015). Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. Lee, C., Revell, M., Porter, K., Steyn, R. (2007). The prehospital management of chest injuries: a consensus statement. Emergency Medicine Journal, 24(3):220-4 Leigh-Smith, S. & Harris, T. 2005. Tension pneumothorax–time for a re-think? Emergency Medicine Journal, 22: 8–16. doi: 10.1136/emj.2003.010421. Netto, F. A. C. S., Shulman, H., Rizoli, S. B., Tremblay, L. N., Brenneman, F., & Tien, H. (2008). Are needle decompressions for tension pneumothoraces being performed appropriately for appropriate indications?. The American journal of emergency medicine, 26(5), 597-602.
Ryan Wilke (2015), Sean Crooks (2016)
ITCB: Tension Pneumothorax
Rutherford, R.B., Hurt, H.H., Brickman, R.D., Tubb, J.M. (1968). The pathophysiology of progressive, tension pneumothorax. Journal of Trauma and Acute Care Surgery, 8: 212–227. doi: 10.1097/00005373196803000-00009. Savage, S. (2011). Tube thoracostomy and emergency needle decompression of tension pneumothorax. In Pfenninger, J.L. & Fowler, G.C. (Eds.), Pfenninger and Fowler's Procedures for Primary Care, Third Edition (pp. 1451-1456). Mosby, Inc. Wax, D.B. & Leibowitz, A.B. (2007). Radiologic assessment of potential sites for needle decompression of a tension pneumothorax. Anesthesia & Analgesia, 105(5):1385. Wernick, B., Hon, H. H., Mubang, R. N., Cipriano, A., Hughes, R., Rankin, D. D., ... & Galwankar, S. C. (2015). Complications of needle thoracostomy: A comprehensive clinical review. International journal of critical illness and injury science, 5(3), 160.
Ryan Wilke (2015), Sean Crooks (2016)
