Tension Pneumothorax

Author: V. Dimov, M.D., Department of Hospital Medicine, Cleveland Clinic

39 yo AAF went to ER with CC: chest pain and SOB. These complaints were of sudden onset while she was typing on her computer. She c/o squeezing, pressure-like sensation in her midsternal area and over her left side. She rated her pain as a 10 on a scale of 1/10.
She had similar complaints recently when she had a left-sided pneumothorax. However, this time she felt worse.

PMH:
SLE and pulmonary fibrosis with a recent left pneumothorax

PSH:
Cholecystectomy, recent thoracotomy with bleb resection for spontaneous pneumothorax

Medications:
Prednisone, Nexium, Doxepin, Atarax

Allergy:
Penicillin, Amoxicillin, reaction unknown

FH:
Breast CA in her sister, lupus in her other sister, HTN, DM

SH:
Stopped smoking 8 years ago

Physical examination:
VS 36.5-78/61-140-20
Chest: Decrease in chest rise and diminished breath sounds on the left side.
CVS: Tachycardic but regular
Abdomen: Soft, NT, ND, +BS

What do you think is going on? Why the BP is low?
Pneumothorax
Pneumonia
Effusion
Atelectasis

What would you order?
CXR
EKG
CPP x 2 q 8 hr
CBCD, CMP

What happened?
12-lead EKG showed sinus tachycardia rhythm with a rate of 139 bpm, no ischemia
CXR showed a complete left pneumothorax with a mediastinum shift - a tension pneumothorax, and a large bulla.


Left-sided pneumothorax and bulla on CXR; Close-up; Lateral CXR

CXR report:
2 views show a large left pneumothorax with near total collapse of the left lung and mediastinal shift to the right with decreased right lung volume and small air fluid level at the left base. Heart is normal size. Conclusion: Severe left tension pneumothorax

CXR report after the chest tube:
Since 15 min ago, limited portable upright view shows partial reexpansion of the left lung, well-placed left drainage tube with return of mediastinum to the midline. There is a large 4.5 x 5 cm bulla in the medial left upper lung. There is partial atelectasis of the left lower lobe.
Conclusion: Partial reexpansion of left lung and markedly improved, decreased left pneumothorax. Resolved tension component of pneumothorax. Large bulla of the medial left upper lobe.

What to do now?
Tension pneumothorax is true life-threatening emergency. Immediately place the patient on 100% oxygen. Do emergency needle decompression without delay. After needle decompression, insert a thoracostomy tube.

The surgical house officer was called and a chest tube was inserted. The repeated CXR several minutes later showed a resolving pneumothorax and a mediastinum in normal position.

What happened after admission?
Patient was admitted to telemetry. AAT deficiency was ruled out.

CT thorax with contrast:

Left-sided pneumothorax and bulla on CT thorax

Impression:
1. Large left pneumothorax, with underlying infiltrate or atelectasis in the left lower lobe; left chest tube noted.
2. Microcystic changes posteriorly at both lung bases, which may reflect interstitial lung disease. 3. Bullous emphysema, more pronounced on the left, where the largest component measures 4 cm in diameter.

A cardiothoracic surgeon was called and the patient had a left thoracotomy which showed several large cystic structures in the left upper lobe. The largest cyst was about 3 cm in diameter in the anterior segment of the left upper lobe, and was ruptured. There were other cystic structures connected to each other in the posterior segment of the left upper lobe. The surgeon excised several cystic structures of the left upper lobe by two wedge resection. Pleurectomy and pleurodesis were done.

Final diagnosis:
Spontanous left tension pneumothorax

What did we learn from this case?
Tension pneumothorax is a true life-threatening emergency. Immediately place the patient on 100% oxygen and do emergency needle decompression without delay.

How to do an emergency needle decompression?
Insert a large-bore 14-16 G needle with a catheter into the second intercostal space at the midclavicular line (1-2 cm from the sternum). Hold the needle at 90 degrees to the chest wall when inserting. Once the needle is in the pleural space, you will hear the hissing sound of escaping air. Remove the needle while leaving the catheter in place. Put a flutter valve.

After needle decompression, insert a thoracostomy tube, which is the definitive treatment for tension pneumothorax.

References:
Tension Pneumothorax - eMedicine 1, 2.

Related:
Bread and Butter. M.D.O.D.
The Pressure Is On. The Happy Hospitalist, 02/2008.

Created: 03/11/2004
Updated: 03/01/2008