2.tension Pneumothorax

TENSION PNEUMOTHORAX
D.R.Queen, MD
VIHAS
YR 2
Overview;
• Definition
• Risk factors/causes
• Pathogenesis
• Clinical features
• Complications
• Differential diagnosis
• Emergency treatment
• Management
Anatomy of the Chest
• The lungs occupy almost the entire chest cavity.

• Each lung is surrounded by a thin serousmembrane called the Visceral Pleura.
• The inner chest wall and Diaphragm is surrounded by the Parietal Pleura.
• In between the Visceral and Parietal Pleura is a “potential” space called the
Pleural Space.
• A small amount of Serous Fluid(10-20MLs) is found in the Pleural Space and
acts as a lubricant and prevents friction between the Visceral and Parietal
Pleura
TENSION PNEUMOTHORAX
DEFINITION:
• Tension pneumothorax is the progressive build-up of air within
the pleural space, usually due to a lung laceration which allows
air to escape into the pleural space but not move out.
• As more air leaks out, filling the pleural space with each
breath, the patient will find it progressively more difficult to
breathe and can impair oxygenation.
ANATOMY -PLEURAL SPACE
Etiology/risk factors
• The most common etiology of tension pneumothorax are either iatrogenic or
related to trauma
TRAUMATIC
 blunt chest trauma,penetrating injury,→the fractured rib end may puncture the
lung. With each breath the patient takes,more and more air accumulates in the
Pleural Space and ultimately leads to Tensioning
SPONTANEOUS/IATROGENIC
 occuring in otherwise asymptomatic individual (usually tall ,thin man) due to
rupture of subpleural bleb, can also occur in COPD,asthmatics&lung cancer
patient
TENSION PNEUMOTHORAX-PATHOPHYSIOLOGY
• There is formation of abnormal,communication between pleural space and
the lung tissue, air escapes from alveoli into the pleural space ,
• Air under pressure builds up progressivelly in the pleural space on the
affected hemithorax,causing collapse of the ipsilateral lung,also compression
of the mediastinum causing madiastinal shift toward contralateral side
compressing the other lung,mediastinal structures eg vasculatures that
enters the right side of the heart.
• Condition develops when injured tissue forms one way valve with the pleural
space allowing air into the pleural space with each breath but preventing
escape naturally.
• This condition rapidly progress to respiratory insufficiency resulting into
hypoxemia eventual cardiovascular collapse and ultimately death if
unrecognized and untreated.
TENSION PNEUMOTHORAX- INTRATHORAX CHANGES
CLINICAL PRESENTATION
Symptoms
• Chest pain
• Progressive dyspnoea
Signs
• Hypoxia/Low SP02
• Hypotension
• Cyanosis
• Decreasing level of conciousness(GCS)
ON EXAMINATION
• Tachycardia
• Ipsilateral decreased air entry or abscent breath sounds
• Jugular venous distention
• Trachea deviation away from the affected side
• Hyper-resonance on percussion
NB SYMPTOMS MAY BE ABSENT !!
• Ultimately one should be guided by the mechanism of injury
• and the presence of significant progressive respiratory
distress.
• Tension pneumothorax is a clinical diagnosis treat without
waiting for chest X-ray
EMERGENCY CARE
• ABCDE FIRST
• A-Airway
 if pt can talk – air way is patent
 NO. look for anything obstructing the airway i.e secretions or foreign
objects- sunction & removal
• B-Breathing
• C-circulation
• D +E-Disability and Exposure
Needle thoracostomy
• Is an emergency, potentially life saving procedure that can be
done if tube thoracostomy cannot be quicky enough
• AIM;reducing intrapleural pressure and improving patient cardiac
output
• It is not a skill to be taken lightly as its invasive nature can be
associated with several dangerous complications
• Equipment
• Sterile gloves
• At least 4 x Disinfectants pads
• 14- 18 gauge needle
• Sterile gown
• mask
Positioning
• Pt should be in supine
Procedure
• Insertion site is the 2nd intercostal space in the midclavicular line on the affected
site
 Recent studies suggest that the 5th Intercostal Space in the Anterior Axillary Line is
significantly thinner than the 2nd Intercostal Space in the Midclavicular Line, thus
increasing the likelihood of needle decompression having a higher success rate.
 In line with current ATLS teaching, I will continue using the 2nd Intercostal Space .
• Prepare the area at and around the insertion site using ant septic solution
• Insert the thoracostomy needle, piercing the skin over the rib below the targeted
interspacethen direct the needle cephalad over the rib until the pleural is
punctured (POP AND/SUDDEN DECREASED IN RESISTENCE)
• There after insert a chest tube as soon as possible
Aftercare
• Chest x ray should be done to comfirm expansion of the lung
and proper placement of the chest tube
Complications of needle thoracostomy
• Hemothorax
• Neuralgia at the insertion site/ nerve injury
• Cardiac temponade- cardiac arrest
• Empyema
• pyopneumothorax
Ddx
• Pulmonary embolism
• Acute coronary syndrome
• Pneumonia
• Rib fructure
investigations
• CXR
 Lack of lung markings
 Flat diaphragm
 Mediastinal shift
• FBP-HB, hematocrit count
Follow up & prevention
• Following a pneumothoraicax patients – needs to be educated
to avoid air travelling until complete resolution or for
maximum of two weeks after surgical intervention

2.tension Pneumothorax

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TENSION PNEUMOTHORAX

• The lungs occupy almost the entire chest cavity.

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