Pneumothorax | Acute Management | ABCDE

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This guide provides an overview of the recognition and immediate management of pneumothorax using an ABCDE approach.

The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working through the following steps:

  • Airway
  • Breathing
  • Circulation
  • Disability
  • Exposure

Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment.

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 of the lung. There are several different ways to classify and name pneumothoraces.

Pneumothoracies can be classified as either primary or secondary:

  • A primary pneumothorax develops in the absence of an underlying disease process.
  • A secondary pneumothorax develops as a result of underlying lung disease such as asthma or COPD.

Pneumothoraces can also be described as 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 a medical emergency due to the resulting sudden rise in intrathoracic pressure which reduces venous return to the heart and ultimately causes cardiac arrest if left untreated.

Symptoms

Typical 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

Typical clinical signs of a pneumothorax include:

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

Tips before you begin

General tips for applying an ABCDE approach in an emergency setting include:

  • Treat all problems as you discover them.
  • Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
  • Make use of the team around you by delegating tasks where appropriate.
  • All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
  • Clearly communicate how often would you like the patient’s observations relayed to you by other staff members.
  • If you require senior input, call for help early using an appropriate SBARR handover structure.
  • Review results as they become available (e.g. laboratory investigations).
  • Make use of your local guidelines and algorithms in managing specific scenarios (e.g. acute asthma).
  • Any medications or fluids will need to be prescribed at the time (in some cases you may be able to delegate this to another member of staff).
  • Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical assessment, investigations and interventions.

Initial steps

Acute scenarios typically begin with a brief handover from a member of the nursing staff including the patient’s nameagebackground and the reason the review has been requested.

Some reasons you may be asked to review a patient with pneumothorax include shortness of breath and chest pain.

Introduction

Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.

Interaction

Introduce yourself to the patient including your name and role.

Ask how the patient is feeling as this may provide some useful information about their current symptoms.

Preparation

Make sure the patient’s notesobservation chart and prescription chart are easily accessible.

Ask for another clinical member of staff to assist you if possible.

If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.


Airway

Clinical assessment

Can the patient talk?

Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.

No:

  • Look for signs of airway compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
  • Open the mouth and inspect: look for anything obstructing the airway such as secretions or a foreign object.
Causes of airway compromise

There is a wide range of possible causes of airway compromise including:

  • Inhaled foreign body: symptoms may include sudden onset shortness of breath and stridor.
  • Blood in the airway: causes include epistaxis, haematemesis and trauma.
  • Vomit/secretions in the airway: causes include alcohol intoxication, head trauma and dysphagia.
  • Soft tissue swelling: causes include anaphylaxis and infection (e.g. quinsy, necrotising fasciitis).
  • Local mass effect: causes include tumours and lymphadenopathy (e.g. lymphoma).
  • Laryngospasm: causes include asthma, gastro-oesophageal reflux disease (GORD) and intubation.
  • Depressed level of consciousness: causes include opioid overdose, head injury and stroke.

Interventions

Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the emergency medical team (often referred to as the ‘crash team’). In the meantime, you can perform some basic airway manoeuvres to help maintain the airway whilst awaiting senior input.

Head-tilt chin-lift manoeuvre

Open the patient’s airway using a head-tilt chin-lift manoeuvre:

1. Place one hand on the patient’s forehead and the other under the chin.

2. Tilt the forehead back whilst lifting the chin forwards to extend the neck.

3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to remove it.

Jaw thrust

If the patient is suspected to have suffered significant trauma with potential spinal involvement, perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre:

1. Identify the angle of the mandible.

2. With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible.

3. Using your thumbs, slightly open the mouth by downward displacement of the chin.

Oropharyngeal airway (Guedel)

Airway adjuncts are often helpful and in some cases essential to maintain a patient’s airway. They should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.

An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration.

To insert an oropharyngeal airway:

1. Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is present, attempt removal using suction.

2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.

3. Advance the airway until it lies within the pharynx.

4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for signs of breathing.

Nasopharyngeal airway (NPA)

A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the NPA.

To insert an oropharyngeal airway:

1. Check the patency of the patient’s right nostril and if required (depending on the model of NPA) insert a safety pin through the flange of the NPA.

2. Lubricate the NPA.

3. Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.

4. If any obstruction is encountered, remove the tube and try the left nostril.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.


Breathing

Clinical assessment

Observations

Review the patient’s respiratory rate:

  • normal respiratory rate is between 12-20 breaths per minute.
  • Tachypnoea is a common feature of pneumothorax and indicates significant respiratory compromise.
  • Bradypnoea in the context of hypoxia is a sign of impending respiratory failure and the need for urgent critical care review.

Review the patient’s oxygen saturation (SpO2):

  • normal SpOrange is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of COretention.

See our guide to performing observations/vital signs for more details.

Examination

Auscultate, palpate and percuss the patient’s lungs fields.

Typical clinical findings in pneumothorax may 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 chest X-ray, if you find clinical signs of pneumothorax (see above) in addition to:

  • Tracheal deviation
  • Raised jugular venous pressure (JVP)

Investigations

Arterial blood gas

Take an ABG if indicated (e.g. low SpO2) to quantify the degree of hypoxia.

Typical ABG findings in pneumothorax include low PaO2 and low PaCO2 (due to hyperventilation). A normal or raised PaCO2 is concerning as it indicates that the patient is tiring and failing to ventilate effectively.

Chest X-ray

A chest X-ray will identify most pneumothoraces.

Typical chest X-ray findings of a pneumothorax 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.

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, mediastinal shift and lung collapse.

A chest X-ray is also useful when trying to rule out other respiratory diagnoses (e.g. pneumonia, pulmonary oedema). Chest X-ray should not delay the emergency management of tension pneumothorax.

Interventions

Oxygen

Administer oxygen to all critically unwell patients during your initial assessment. This typically involves the use of a non-rebreathe mask with an oxygen flow rate of 15L. You can then trial titrating oxygen levels downwards after your initial assessment.

If the patient is conscious, sit them upright as this can also help with oxygenation.

Management of simple pneumothorax

There are very clear guidelines from the British Thoracic Society (BTS) on how to treat pneumothorax.1

Management differs depending on several factors including:

  • If the patient has a history of smoking or underlying lung disease (more likely to have a secondary pneumothorax)
  • Age of the patient
  • Size of the pneumothorax
  • Degree of breathlessness
  • Response to treatment

Management options

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):

  • Patients with a large primary pneumothorax
  • Symptomatic patients
  • Patients with a small secondary pneumothorax

Admit and administer high flow oxygen and observe:

  • Patients with a small (<1cm) secondary pneumothorax
  • Patients who have undergone aspiration of the air

Chest drain insertion and admission:

  • Patients who have not improved following aspiration
  • Patients with large secondary pneumothoraces

Management of tension pneumothorax

Tension pneumothorax requires immediate treatment with needle decompression.

Needle decompression involves placing a needle or cannula into the 2nd intercostal space, mid-clavicular line (on the affected side) to immediately relieve the tension pneumothorax.

A chest drain can then be inserted once the initial decompression has been performed.

If you think you are dealing with a tension pneumothorax you should ask someone to put out a peri-arrest call on 2222.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.


Circulation

Clinical assessment

Pulse

Patients with pneumothorax may be tachycardic due to pain, anxiety or reduced oxygen saturation.

Bradycardia is a late sign of a tension pneumothorax.

Blood pressure

Pain and anxiety may lead to hypertension.

Hypotension is a late sign of a tension pneumothorax.

Capillary refill time

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

Jugular venous pressure (JVP)

An elevated JVP may be apparent in tension pneumothorax due to increased intrathoracic pressure.

Fluid balance assessment

Calculate the patient’s fluid balance:

  • Calculate the patient’s current fluid balance using their fluid balance chart (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts.
  • Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult.

Investigations and procedures

Intravenous cannulation

Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.

See our intravenous cannulation guide for more details.

Blood tests

Blood test results are unlikely to change the initial management of pneumothorax but may be useful in the diagnosis of underlying causes (e.g. pneumonia).

Collect blood tests after cannulating the patient including:

  • FBC: to rule out anaemia and to look for a raised white cell count which may suggest underlying infection.
  • U&Es
  • LFTs
  • CRP: to screen for evidence of inflammation (e.g. pneumonia).
  • Coagulation: to screen for clotting abnormalities that might alter management (e.g. decision on inserting a chest drain).

Record an ECG

An ECG can be useful to help exclude cardiac causes of chest pain if these are suspected.

An ECG will likely be normal in the context of pneumothorax.

Performing an ECG should not delay your initial management of the pneumothorax.

Interventions

Intravenous fluids

Hypovolaemic patients require fluid resuscitation (the below guidelines are for adults):

  • Administer a 500ml bolus Hartmann’s solution or 0.9% sodium chloride (warmed if available) over 15 mins.
  • Administer 250ml boluses in patients at increased risk of fluid overload (e.g. heart failure).

After each fluid bolus, reassess for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP).

Repeat administration of fluid boluses up to four times (e.g. 2000ml or 1000ml in patients at increased risk of fluid overload), reassessing the patient each time.

Seek senior input if the patient has a negative response (e.g. increased chest crackles) or if the patient isn’t responding adequately to repeated boluses (e.g. persistent hypotension).

See our fluid prescribing guide for more details on resuscitation fluids.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.


Disability

Clinical assessment

Consciousness

In the context of pneumothorax, a patient’s consciousness level may be reduced secondary to hypoxia or cardiac tamponade in tension pneumothorax.

Assess the patient’s level of consciousness using the AVPU scale:

  • Alert: the patient is fully alert, although not necessarily orientated.
  • Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt).
  • Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure).
  • Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain.

If a more detailed assessment of the patient’s level of consciousness is required, use the Glasgow Coma Scale (GCS).

Pupils

Assess the patient’s pupils:

  • Inspect the size and symmetry of the patient’s pupils. Asymmetrical pupillary size may indicate intracerebral pathology.
  • Assess direct and consensual pupillary responses which may reveal evidence of intracranial pathology or lung cancer (e.g. Horner’s syndrome).

Drug chart review

Review the patient’s drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives, anxiolytics).

Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient’s airway.

Investigations

Blood glucose and ketones

Measure the patient’s capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g. hypoglycaemia or hyperglycaemia). The normal reference range for capillary blood glucose is 4.0-11.0 mmol/L.

A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).

If the blood glucose is elevated, check ketone levels which if also elevated may suggest a diagnosis of diabetic ketoacidosis (DKA).

See our blood glucose measurement, hypoglycaemia and diabetic ketoacidosis guides for more details.

Imaging

Request a CT head if intracranial pathology is suspected after discussion with a senior.

See our guide on interpreting a CT head for more details.

Interventions

Maintain the airway

Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient’s airway as explained in the airway section of this guide.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.


Exposure

It may be necessary to expose the patient during your assessment: remember to prioritise patient dignity and conservation of body heat. 

Clinical assessment

Inspection

Inspect for evidence of chest trauma (e.g. penetrating chest trauma in tension pneumothorax) and injuries elsewhere.

Review the output of the patient’s catheter and any surgical drains for blood loss and fluid loss to guide intravenous fluid replacement.

Bleeding

If active bleeding is identified:

  • Estimate the total blood loss and the rate of blood loss.
  • Re-assess for signs of hypovolaemic shock (e.g. hypotension, tachycardia, pre-syncope, syncope).

Temperature

Assess the patient’s temperature: fever may indicate an infective cause underlying pneumothorax (e.g. pneumonia).

Investigations

Further imaging

Further imaging may be required in the context of trauma, such as CT thorax, however, this should not delay initial management of pneumothorax.

Group and save

If the patient is bleeding or may require surgery send a group, save +/- crossmatch if not already performed.

Interventions

Trauma and bleeding

If the patient has suffered significant trauma, provide pain relief and contact appropriate specialists depending on the injury (e.g. orthopaedic surgery, plastic surgery, vascular surgery).

If the patient has lost a significant amount of blood they will likely require a blood transfusion.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.


Reassess ABCDE

Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.

Deterioration should be recognised quickly and acted upon immediately.

Seek senior help if the patient shows no signs of improvement or if you have any concerns.

Support

You should have another member of the clinical team aiding you in your ABCDE assessment, such a nurse, who can perform observations, take samples to the lab and catheterise if appropriate.

You may need further help or advice from a senior staff member and you should not delay seeking help if you have concerns about your patient.

Use an effective SBARR handover to communicate the key information effectively to other medical staff.


Next steps

Well done, you’ve now stabilised the patient and they’re doing much better. There are just a few more things to do…

Take a history

Revisit history taking to identify risk factors for PE and explore relevant medical history. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate.

See our history taking guides for more details.

Review

Review the patient’s notes, charts and recent investigation results.

Review the patient’s current medications and check any regular medications are prescribed appropriately.

Document

Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.

See our documentation guides for more details.

Discuss

Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover.

Questions which may need to be considered include:

  • Are any further assessments or interventions required?
  • Does the patient need a referral to HDU/ICU?
  • Does the patient need reviewing by a specialist?
  • Should any changes be made to the current management of their underlying condition(s)?

Handover

The next team of doctors on shift should be made aware of any patient in their department who has recently deteriorated.


References

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

 

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