Tension Pneumothorax

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

A 39-year-old African American female (AAF) went to the emergency department (ED) with a chief complaint (CC) of chest pain and shortness of breath (SOB). These complaints were of sudden onset and started while she was typing on her computer. She complained of (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.

Past medical history (PMH)

Systemic lupus erythematosus (SLE) and pulmonary fibrosis with a recent left pneumothorax.

Past surgical history (PSH)

Cholecystectomy, recent thoracotomy with bleb resection for spontaneous pneumothorax.

Medications

Prednisone, esomeprazole (Nexium), doxepin, hydroxyzine (Atarax).

Allergy

Penicillin, amoxicillin, reaction unknown.

Family history (FH)

Breast CA in her sister, lupus in her other sister, hypertension (HTN), diabetes type 2 (DM2).

Social history (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 is the most likely diagnosis?

Why the blood pressure (BP) is low?
Pneumothorax?
Pneumonia?
Effusion?
Atelectasis?

What diagnostic workup would you recommend?

CXR?
EKG?
Cardiac enzymes (sometimes called chest pain panel, CPP) x 2 q 8 hr?
CBCD, CMP?

What happened?

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


A left-sided pneumothorax and bulla on CXR (left); Close-up (middle); Lateral CXR (right) (click to enlarge the images).

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 is the next step in the management of this patient? 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?

The patient was admitted to telemetry. Alpha 1-antitrypsin deficiency (A1AT) deficiency was ruled out.


CT thorax with contrast: Left-sided pneumothorax and bulla on CT thorax (click to enlarge the images).

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 Specialties > Trauma > Thoracic Trauma, 2009.
Pneumothorax, Tension and Traumatic. eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics, 2009.

Related reading

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

Published: 03/11/2004
Updated: 11/01/2009

4 comments:

  1. Very good post. I have seen a couple of patients with this problem. UreSil catheter would also be appropriate in this case.
    Once I saw a patient with spantaneous pneumomediastinum and SQ emphysema. This is quite rare.

    ReplyDelete
  2. Ralph,

    You can see a case of subcutaneous emphysema here:
    http://clinicalcases.org/2004/02/complications-of-central-line.html

    ReplyDelete
  3. Yes, thank you. It is quite impressive.

    ReplyDelete
  4. Great presentation and explanation of the clinical cases.

    ReplyDelete