Tension

Pneumothorax
Anak Agung Istri Intan Yuniari
Anatomy
• Pleura fluid separates parietal and
visceral pleural surfaces.

• Amount of pleural fluid in 24 hours: 0,3

ml/kg or 25 ml.

• Fluid reduces friction, allowing the

pleura to slide easily during breathing.
Physiology
Mechanics of
Breathing
 Pleural Physiology

• Area between the pleura  the pleural space (potential

space)

• Inspiration: -7 cmH2O
• Exhalation : -4 cmH2O

Guyton AC.Textbook of Medical Physiology 11th ed

 Intrapulmonary pressure (the
pressure in the lung)
• rises and falls with breathing
Pressure Intrapleural pressure also
fluctuates with breathing
• ~ 4 cmH2O less than the
intrapulmonary pressure
Atmospheric pressure
The pressure difference of 4
cmH2O across the alveolar
wall creates the force that
keeps the stretched lungs
adherent to the chest wall
 Life-threatening condition caused by the continuous
entrance and entrapment of air into the pleural space

Tension pneumothorax develops when a “one-way valve”

air leak occurs from the lung or through the chest wall

Tension
Pneumothorax Air is forced into the pleural space with no means of escape,
eventually collapsing the affected lung. The mediastinum is
displaced to the opposite side, decreasing venous return and
compressing the opposite lung.

The most common cause of tension pneumothorax is

mechanical positive-pressure ventilation in patients with
visceral pleural injury
• In the conscious patient there is a compensatory mechanism with tachypnea, tidal volume, air hunger, and
tachycardia.

• If the body is unable to compensate, there will be a decompression phase and progressive respiratory
failure occurs
• Traumatic defects in the chest wall cause a tension pneumothorax when occlusive dressings are secured
on four sides or the defect itself constitutes a flap-valve mechanism

• Tension pneumothorax is a clinical diagnosis reflecting air under pressure in the affected pleural space.
Do not delay treatment to obtain radiologic confirmation.

Clinical diagnosis defined as “any pneumothorax with

cardiorespiratory compromise or collapse”
Sign and symptoms
• Chest pain • Tracheal deviation away from the side of the
injury
• Air hunger
• Unilateral absence of breath sounds
• Tachypnea
• Elevated hemithorax without respiratory
• Respiratory distress movement
• Tachycardia • Neck vein distention
• Hypotension • Cyanosis (late manifestation)
Tension pneumothorax should be suspected in
any intubated or postoperative patient
developing hypotension

A hyperresonant note on percussion, deviated

trachea, distended neck veins, and absent
breath sounds are signs of tension
pneumothorax. Arterial saturation should be
assessed using a pulse oximeter and will be
decreased when tension pneumothorax is
present.
Management
• Require immediate decompression by
inserting a large needle catheter into
pleural space

• The needle should be at least 7 cm long

and inserted in the midclavicular line at
the second intercostal space.

• Tube thoracostomy is mandatory after

needle or finger decompression of the
chest.
Management
Tension
Pneumothorax
Immediate decompression
Secure the airway
Optimize oxygenation
Needle decompression

Chest wall thickness influences the likelihood of success with needle decompression

a 5-cm over-the-needle catheter will reach the pleural space >50% of the time

an 8-cm over- the-needle catheter will reach the pleural space >90% of the time.

Recent evidence supports placing the large, over-the-needle catheter at the fifth interspace, slightly
anterior to the midaxillary line
Successful needle decompression converts tension pneumothorax to a simple pneumothorax.
Insertion Site
Midclavicular line 2nd ICS ~ For
emergencies needle (Tension
Pneumothorax)
Insertion Site
Triangle of safety (Mid Axillary Line) 4th or
5th ICS
Technique

Choose site

Explore with finger

Place tube with clamp

Suture tube to chest

Indications
Emergency Non Emergency

Tension Pneumothorax Malignant Pleural Effusion

Unstable Hemodynamic Traumatic Recurrent Pleural Effusion

hemopneumothorax
Parapneumonic effusion or empyema

Chylothorax

Post care (after cardiac, pulmonary,

mediastinal or pleural)

Post pneumonectomy bronchopleural

fistula
How do we know whether the Chest
Drain properly functional or not?
• Positive Undulation (Prove of connection between the tube and
intrathoracic cavity)

• Less Painful (Appropriate place and Tube Size)

• Correct Pressure (Enough Negative Pressure)

• Bubble Production (Pneumothorax)

• Drainage Production (Amount, and Type of Fluid)

 Infection

Laceration of lung tissue

Intraabdominal organ laceration

Complication
Bleeding

Subcutis Emphysema

Malposition
Wuryanto, Nugroho A, Sanuar R. Manual Pemasangan WSD. Badan Penerbit Fakultas Kedokteran Universitas Indonesia. 2011