How to treat a tension pneumothorax

Tension pneumothorax represents an accumulation of air under pressure in the pleural space. It presents in cases of injured tissue that allows the air to enter the pleural space. At the same time, it prevents it from escaping naturally. Multiple causes may be responsible for this condition. It rapidly progresses to respiratory insufficiency, cardiovascular collapse, and possibly death. To avoid this outcome, a timely diagnosis and urgent disease management are of critical value.

A fast diagnosis can save a life. Tension pneumothorax is quite rare but with ill effects. As a result, the personnel dealing with this condition need to be highly trained in specific fields.

Without appropriate testing, tension pneumothorax is virtually impossible to trace. As for the medical treatment, an immediate needle decompression of the chest is well advised. Not all suspected patients truly suffer from tension pneumothorax. However, disregarding the possible condition may result in the death of the patient, so vigilance is recommended.

Tension pneumothorax is an immediate threat to life. Treatment in the prehospital setting is usually achieved by needle thoracostomy (NT). Prehospital personnel are taught to perform NT, frequently in the second intercostal space (ICS) at the mid-clavicular line (MCL). Previous literature has suggested that emergency physicians have difficulty identifying this anatomic location correctly. We hypothesized that paramedics would also have difficulty accurately identifying the proper location for NT.

A prospective, observational study was performed to assess paramedic ability to identify the location for treatment with NT. Participants were recruited during a statewide Emergency Medical Services (EMS) conference. Subjects were asked the anatomic site for NT and asked to mark the site on a shirtless male volunteer. The site was copied onto a transparent sheet lined up against predetermined points on the volunteer’s chest. It was then compared against the correct location that had been identified using palpation, measuring tape, and ultrasound.
29 paramedics participated, with 24 (83%) in practice for more than five years and 23 (79%) doing mostly or all 9-1-1 response. All subjects (100%) reported training in NT, although six (21%) had never performed a NT in the field. Nine paramedics (31%) recognized the second ICS at the MCL as the desired site for NT, with 12 (41%) specifying only the second ICS, 11 (38%) specifying second or third ICS, and six (21%) naming a different location (third, fourth, or fifth ICS).
None (0%) of the 29 paramedics identified the exact second ICS MCL on the volunteer. Mean distance from the second ICS MCL was 1.37 cm (interquartile range (IQR): 0.7-1.90) in the medial-lateral direction and 2.43 cm in the superior-inferior direction (IQR: 1.10-3.70). Overall mean distance was 3.12 cm from the correct location (IQR: 1.90-4.50).
Most commonly, the identified location was too inferior (93%). Allowing for a 2 cm radius from the correct position, eight (28%) approximated the correct placement. 25 (86%) were within a 5 cm radius.

✓ Fact confirmed: Paramedic Understanding of Tension Pneumothorax and Needle Thoracostomy (NT) Site Selection Jeffrey S. Lubin, Joshua Knapp, and Maude L. Kettenmann; 2022 Jul 19.

Tension Pneumothorax Treatment

Noninvasive therapy is practically non-existent when it comes to tension pneumothorax.

Tension pneumothorax, being a life-threatening condition, requires urgent addressing. Treatment is not to be delayed for any reason.

The patient should be placed on 100 percent oxygen. Emergency needle decompression is to be administered as soon as possible. Preparation for a thoracostomy tube insertion ensues. After reassessing the patient’s condition the patient may be found to need additional thoracostomy tubes. The patient should be monitored continuously for signs of arterial oxygen saturation.

All patients with this disease are to be admitted without delay.

A needle decompression is a procedure by which a catheter is introduced into the pleural space. This produces a path for the air to escape, relieving the existing pressure. Even though an emergent needle decompression is not considered to be a definitive treatment for tension pneumothorax, it is known to arrest its progression and restore cardiopulmonary function in a small amount.

Anatomic landmarks are to be located and the area in question should be prepared for an iodine-based solution puncture. A large-bore catheter needle is to be inserted into the intercostal space. The catheter should then be positioned perpendicularly to the chest wall during the insertion process. The doctor should listen for a hissing sound while the needle is in the pleural space. The needle should be removed, leaving the catheter in place. Preparation for tube thoracostomy ensues.

The tube thoracostomy is a sure treatment for tension pneumothorax. After locating the landmarks, a local anesthetic should be applied. The area is prepared with an iodine solution and drape. A one-inch incision is then made, over the fifth or sixth rib along the midaxillary line.

A curved hemostat will dissect the soft tissue all the way down to the rib. What follows is a puncture of the intercostal muscles and parietal pleura. The chest tube is inserted into the pleural space. Correct placement will be highlighted by condensation in the tube. The tube is then sutured in place and taped to the chest, and the wound is dressed appropriately.