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All types of pneumothorax have the potential to become a tension pneumothorax, which is life-threatening and must be recognised and treated in a timely manner. A tension pneumothorax is one of the 4Hs and 4Ts of reversible cardiac arrest. You can read more about the 4Hs and 4Ts here.

This guide gives an overview of the recognition and immediate management of pneumothorax using the ABCDE approach. You can check out our overview of the ABCDE approach here.

This guide has been created to assist students in preparing for emergency simulation sessions as part of their training. It is not intended to be relied upon for patient care.

 


Clinical features of a pneumothorax

A pneumothorax is a collection of air between the parietal and visceral pleura.

There are several different ways to classify and name pneumothoraces.

Most simply, a pneumothorax can be either primary or secondary:

  • A primary pneumothorax occurs without any underlying disease.
  • A secondary pneumothorax is due to underlying lung disease such as asthma or COPD.

Pneumothoraces can also be described as either spontaneous or traumatic (e.g. occurring secondary to penetrating chest trauma).

 

Tension pneumothorax

All types of pneumothorax can potentially develop into a tension pneumothorax.

A tension pneumothorax is life-threatening because it results in a sudden rise in intrathoracic pressure which reduces venous return to the heart and ultimately causes cardiac arrest.

 

Symptoms

Classical symptoms of a pneumothorax include:

  • Sudden onset chest pain
  • Acute shortness of breath
  • A feeling of not being able to take a full breath

 

Signs

Classical clinical signs include:

  • Tachypnoea
  • Tachycardia
  • Hypoxia
  • Reduced breath sounds on the affected side
  • Hyperresonance on the affected side
  • Tracheal deviation (away from the affected side) is a clinical sign of tension pneumothorax and warrants prompt treatment with decompression

 


Tips before you begin

  • Treat all problems as you find them
  • Reassess regularly and after every intervention to see if your management is effective
  • Make use of the team around you to delegate tasks where appropriate
  • All critically unwell patients should have continuous monitoring equipment attached for accurate observations including:
    • Blood pressure
    • 3-lead ECG
    • Oxygen saturations
    • Heart rate
    • Respiratory rate
  • Communicate how often you would like these observations to be relayed to you
  • Call for help early using an appropriate SBARR handover structure (check out the guide here)
  • You need to both request investigations and review results as they become available
  • You don’t have to memorise everything off by heart, ask for guidelines and algorithms that are relevant (i.e. pneumothorax treatment guidelines)
  • If you would like medications or fluids, these will need to be prescribed
  • Don’t forget to document everything you have found and done in the patient notes!

 


Initial steps

You are likely to be called to see this patient as a new presentation to ED with chest pain and/or shortness of breath.

 

Inspection

Perform a quick general inspection of the patient to get a sense of how unwell they are:

  • If the patient is unconscious, check for a pulse and check that the patient is breathing.

 

If the patient is unconscious or unresponsive and not breathing start the basic life support (BLS) algorithm as per resuscitation guidelines. Call 2222 for help! (see our BLS guide here)

  • Perform AVPU and assess their consciousness level
  • How do they look?
  • What is their breathing like?
  • Are there any clues from around the bedside? (look for drug charts, medication, IV lines, monitoring equipment etc)

Interaction

  • Introduce yourself to the patient
  • If the patient is able to answer questions, ask how they are feeling

Preparation

Ensure you have as much information as possible available to you

  • Patient notes
  • Drug charts including diabetes charts
  • Observations charts
  • Does this patient have an underlying lung condition? (e.g. COPD, cystic fibrosis, pneumonia or lung cancer)
  • Is the patient a smoker?

 


Airway

Assessment

Assess the patient’s ability to speak, listen to the patient’s breathing for added sounds and inspect the mouth.

 

Intervention

If you think your patient has a compromised airway you need help.

Put out a crash call immediately as you require urgent anaesthetic input to secure the airway.

You can perform some simple airway manoeuvres in the meantime.

 

Maintaining the airway whilst awaiting senior support

1. Perform a head tilt, chin lift manoeuvre.

2. If noisy breathing persists, try a jaw thrust.

3.  If this is still not enough to open up the airway you can consider the use of an airway adjunct:

  • If your patient is still semi-conscious then consider using a nasopharyngeal (NP) airway.
  • If your patient is able to tolerate an oropharyngeal (OP, or Guedel) airway then you can use one of these. However, this indicates that your patient is seriously unwell as they no longer have a gag reflex.

 

Reassess after any intervention

If your patient starts to improve throughout your assessment, they may no longer be able to tolerate the OP airway and you should remove it as soon as possible to prevent gagging/aspiration.

 


Breathing

Assessment

Oxygen saturation

  • Aim for 94-98%
  • If the patient has COPD with known CO2 retention then you can consider aiming for an oxygen saturation range of 88-92%, however, in an acute setting, it is often acceptable to commence high-flow oxygen and then titrate down once the patient has stabilised

 

Respiratory rate

  • Tachypnoea is the body’s response to hypoxia
  • Impaired consciousness may lead to a reduced respiratory rate (bradypnoea)

Examination

Auscultate, palpate and percuss both lungs

Examination findings during the assessment of the chest in pneumothorax include:

  • Unilaterally reduced chest expansion
  • Unilateral hyper-resonance
  • Unilaterally reduced air entry

 

A tension pneumothorax is a clinical diagnosis.

Treat for a tension pneumothorax immediately (without waiting for a CXR) if you find clinical signs of a pneumothorax in addition to:

  • Tracheal deviation
  • Raised jugular venous pressure (JVP)

Investigations

Arterial blood gas

  • An arterial blood gas may be useful to quantify the degree of hypoxia if your patient has low oxygen saturations.
  • ABG results in pneumothorax may show low PaO2 and normal/low PaCO2 due to hyperventilation.

 

Chest x-ray

  • A CXR will identify most pneumothoraces
  • Typical CXR findings include:
    • Air in the pleural space
    • Decreased lung markings around the outer edge of the lung field
    • Lung collapse
  • Small pneumothoraxes can be difficult to see on the CXR, especially if you aren’t looking for them!
  • There may be an indication to request a CT scan of the chest if you are uncertain of the diagnosis but you should speak to a senior about this

 

A chest x-ray showing a tension pneumothorax should ideally never be seen, as it should have been identified during clinical examination and treated immediately.

If, however, a chest x-ray was performed, you would expect to see visible tracheal deviation and lung collapse.

 

Intervention

Oxygen

  • Administer oxygen as soon as possible
    • High-flow oxygen (15 litres) through a non-rebreathe mask
  • If the patient is conscious, sit them upright
  • Maintain oxygen saturations between 94-98%

Simple pneumothorax treatment

There are very clear guidelines from the British Thoracic Society (BTS) on how to treat a pneumothorax.

The choice of treatment depends on:

  • History of smoking or underlying lung disease (secondary pneumothoraces)
  • Age
  • Size of pneumothorax
  • Degree of breathlessness
  • Response to treatment

 

The BTS guidelines for a simple pneumothorax (not tension) can be found in full here, but the key management options are summarised below.

  • Consider discharge and review in 2-4 weeks:
    • This is for patients with a small primary pneumothorax and no breathlessness
  • Aspirate with a 16-18G cannula (up to 2.5L):
    • This is for patients with a large primary pneumothorax
    • or those who are symptomatic
    • or for patients with a small secondary pneumothorax
  • Admit and administer high flow oxygen and observe:
    • This is for patients with a very small (<1cm) secondary pneumothorax
    • or for those who have had already had an aspirate done
  • Chest drain insertion and admission:
    • This is for patients who have not improved following aspiration
    • or for large secondary pneumothoraces

Tension pneumothorax treatment

  • Tension pneumothorax requires immediate treatment.
  • The definitive treatment will be a chest drain insertion, however, as this can take a couple of minutes to arrange and set up, a needle decompression is indicated initially.
  • If you think you are dealing with a tension pneumothorax you will need help ASAP.
  • This scenario would warrant putting out a peri-arrest call on 2222.
  • Needle decompression involves placing a needle or cannula into the 2nd intercostal space, mid-clavicular line (on the affected side) to immediately relieve some tension.
  • After this has been done you can proceed to chest drain insertion.

 

Reassess after any intervention

 


Circulation

Assessment

Pulse

  • Your patient may be tachycardic or have a normal heart rate (depending on pain, size of pneumothorax and anxiety levels)
  • Bradycardia may be a late sign of a tension pneumothorax if there is sufficient intra-thoracic pressure to compress the heart

 

Blood pressure

  • Pain and anxiety may lead to hypertension
  • Hypotension is, again, a late sign of a tension pneumothorax

 

Examination

  • Your patient may appear cyanosed
  • Capillary refill time may be reduced if the patient is hypotensive (e.g. tension pneumothorax)

Investigations

Take blood samples

  • Try if possible to collect blood samples during cannulation
  • Blood results will be unlikely to change your initial management of pneumothorax, but may be useful in the diagnosis of underlying causes (e.g. pneumonia)
  • Full Blood Count: For a haemoglobin and platelet measurement. You can also look for markers of infection.
  • CRP: For markers of infection/inflammation.
  • Urea and Electrolytes: To assess renal function
  • Liver Function Tests and Clotting

 

 

Record an ECG

  • This should not delay your management of the pneumothorax.

Intervention

Secure intravenous access

  • The gold standard is to insert 2 large bore cannulas for acutely unwell patients.

 

Administer IV fluids

  • Titrate your fluids to the patient’s level of haemodynamic instability
  • Typically NaCl 0.9% or Hartmann’s solution is used for fluid resuscitation

 

Reassess after any intervention

 


Disability

Assessment

Assess pupils

  • What size are they?
  • Are they equal?
  • Are they reactive to light?

 

Assess level of consciousness- AVPU/GCS

  • The above Airway, Breathing and Circulation problems can all alter the patient’s neurological status because of decreased cerebral perfusion, causing the patient to be confused or drowsy.
  • A formal record of your patient’s consciousness level will be really useful for tracking progress and changes throughout treatment.

 

Reassess after any intervention

 


Exposure

Assessment

Inspection

  • We routinely expose all unwell patients to make sure that we aren’t missing anything.

 

Temperature

  • A fever might indicate an underlying infection (e.g. pneumonia).

 

Urine output

  • Urine output will likely need monitoring if administering fluids, to ensure an accurate fluid balance is recorded.

Reassess after any intervention

 


Reassess ABCDE

It is essential to continually reassess ABCDE and treat issues as you encounter them. This allows continual reassessment of the response to treatment and early recognition of deterioration.

 


Next steps

Well done! You have successfully implemented the immediate treatment for your patient. Your patient has been started on appropriate treatment and their observations are improving. There are just a few more things to do…

Take a history

If possible, it is important to revisit history taking to clarify risk factors for pneumothorax (e.g. trauma or underlying respiratory conditions) and other relevant medical information. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate. Check out the history taking guides here.

 

Review

  • Patient notes
  • Observation charts
  • Fluid charts
  • Investigation findings
  • Additionally, make sure to check the medications you have just prescribed and what the patient normally takes. This helps reduce prescribing errors and allows you to consider any possible drug interactions.

Document

It is really important that you document your initial ABCDE findings, any interventions you made and the response the patient had to those interventions. Also, make sure to document salient points from the history.

Discuss

You need to discuss the patient with the medical team. If your patient requires a higher level of care (HDU/ICU) then you need to speak to the appropriate teams directly.

As a junior doctor it would be appropriate to give an SBARR handover outlining your assessment and actions, and to discuss the following:

  • Does the patient need a referral to HDU/ICU?
  • Does the patient need further treatment?
  • Are there any further assessments, investigations or interventions required?
    • For example, will the patient need a repeat CXR to check chest drain position or to see if aspiration has been successful in treating the pneumothorax?
  • Should they be referred for a review by a specialist doctor (e.g. a respiratory physician)?
  • Should any changes be made to the management of their underlying conditions?

 


References

1. BTS Guidelines. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. [Available here]

 


 

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