Tension pneumothorax

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  • Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest

Clinical Features

  • Unilateral diminished or absent breath sounds
  • Hypotension or evidence of hypoperfusion
  • Distended neck veins
    • May not occur if patient is hypovolemic
  • Contralateral Tracheal deviation (late sign)
  • Type of obstructive shock since prevents venous return to the right side of the heart

Differential Diagnosis

Pneumothorax Types

Thoracic Trauma

Acute dyspnea




Left sided tension pneumothorax with mediastinal shift

Ideally a clinical diagnosis treated emergently (without delay for studies)

Lung ultrasound of pneumothorax

  • No lung sliding seen (not specific for pneumothorax)
  • May also identify "lung point": distinct point where you no longer see lung sliding (pathognomonic)
  • Absence of lung sliding WITHOUT lung point could represent apnea or right mainstem intubation
  • Evaluate other intercostal spaces because pneumothorax may only be seen in least dependent area of thorax
    • NO comet tail artifact
    • Bar Code appearance/"Stratosphere" sign on M-mode (absence of "seashore" waves)
  • Ultrasound has greater sensitivity than chest x-ray for pneumothorax in trauma patients [1]


  • Immediate needle thoracostomy
    • 14ga IV in midclavicular line just above the rib at the second intercostal space
    • Evidence suggests lowest failure rate of needle decompression is at the 4th/5th rib space along the anterior axillary line [2]
  • Always followed by Chest Tube placement

Pediatric Chest Tube

  • Estimated as 4*ETT
    • ETT=(4+age/4)

Adult Chest Tube Sizes

Chest Tube Size Type of Patient Underlying Causes
Small (8-14 Fr)
  • Alveolar-pleural fistulae (small air leak)
  • Iatrogenic air
Medium (20-28 Fr)
  • Trauma/bleeding (hemothorax/hemopneumothorax)
  • Bronchial-pleural fistulae (large air leak)
  • Malignant fluid
Large (36-40 Fr)
  • Thick pus


  • Admit

Special Instructions


  • Can consider flying 2 weeks after full resolution of traumatic pneumothroax[5]


See Also


  1. Nagarsheth K, Kurek S. Ultrasound detection of pneumothorax compared with chest X-ray and computed tomography scan. Am Surg. 2011 Apr;77(4):480-4. PMID: 21679560.
  2. Laan DV et al. Chest Wall Thickness and Decompression Failure: A systematic Review and Meta-Analysis Coparing Anatomic Locations in Needle Thoracostomy. Injury 2015 [Epub Ahead of Print]. PMID: 26724173
  3. Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
  4. Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.
  5. "Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010" British Thoracic Society Guidelines. Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 PDF