Page 59 - JSOM Winter 2024

Traumatic Tension Pneumothorax

A Tale of Two Pathologies

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Patrick Thompson, MSc *; Jay Johannigman, MD FACS ; Anthony Hudson, MA, MBBS FRCP FRCEM DTM&H ;
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Timm Irvine-Smith, BA, LLB ; Nicholas Reis, DO ; Roxolana Horbowyj, MS, MD ; Kristin Fagereng, MD ;
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Kevin R. Ward, MD ; Marc De Pasquale, BSc ; Runar Salte, BS ; Christopher K. Bjerkvig, MD, PhD ;
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Martin Rognhaug, MSc ; Marius Svanevik, MD, PhD ; Håkon Eliassen, MD, PhD ; Sara Magnusson, MD ;
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Stefan Hellander, MD ; Stefan Enbuske, MD ; Pierre Stroberg, CRNA ; Marcus Larsson, MD ;
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Christopher B. R. Funk, MD ; Dylan Pannell, MD, PhD ; Jo Schmid, RN, BScN ; Isabelle Vallee, MD ;
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Iain Vergie, MD ; Allan J. Taylor, MD ; Jason Toole ; Elon Glassberg, MD, MHA, MBA ;
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Ofer Almog, MD, MHA ; Patricio F. Vasquez ; Gabriel Valdez ; Andrew S. Oh, MD ; Charles H. Moore, MD ;
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Brent M. Barbour, DO ; Rodney C. Isaacs ; Leo A. Perez ; Ronald D. Hardin Jr., MD, FACS ;
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Brendan J. Killian, RN ; Rachel E. Bridwell, MD ; Matthew B. Harrison ; Jennifer M. Gurney, MD ;
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Geir Strandenes, MD ; Maxwell A. Braverman, DO, FACS 42
ABSTRACT
Pneumothorax resulting from injury is a common phenome- Keywords: pneumothorax; simple pneumothorax; tension
non in both civilian and military trauma. A pneumothorax or pneumothorax
simple pneumothorax is defined as air in the pleural space. A
tension pneumothorax can evolve from a simple pneumotho-
rax if there is a continued air leak from the lung without mech- Introduction
anism for egress. This occurs due to an expanding air volume
and pressure in the pleural space. The tension pneumothorax An examination of data on 4,596 combat deaths during the
results in obstructive shock that may be a life-threatening emer- first decade of combat operations during Operation Iraqi Free-
gency. All types of pneumothorax can occur in patients who dom (OIF) and Operation Enduring Freedom (OEF) revealed
are spontaneously breathing as well as those receiving posi- that 24.3% of combat deaths were from potentially surviv-
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tive pressure ventilation. Positive pressure ventilation changes able injuries. Tension pneumothorax was noted in 11 of 976
the dynamics of pneumothoraces in that it can exacerbate an casualties. This equates to 1.1% of the potentially survivable
air leak, resulting in a simple pneumothorax evolving into a group, suggesting that tension pneumothorax is relatively rare
tension pneumothorax. The pathophysiology and clinical pre- in the spectrum of combat-related mortality that could be
sentation of these traumatic conditions represent two differing preventable. 1
sub-pathologies, and, although they share the same underlying
physiological process, in the opinion of the authors, a different In civilian practice, traumatic pneumothorax is the most
approach should be adopted when considering treatment. common life-threatening injury associated with blunt chest
trauma, occurring in over 20% of patients with blunt injuries
The objective of this manuscript is to discuss the etiology, in- and about 40% with penetrating chest injuries. The preva-
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cidence, and clinical significance of simple and tension pneu- lence of tension pneumothorax in the civilian population is
mothoraces. This paper will propose a uniform description of debated, but an estimate of <6% of patients presenting with
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pathophysiology and diagnostic elements as well as treatment thoracic injury has been suggested. A risk-benefit analysis is
strategies. The intent is to provide a standardization of the required to optimize outcomes and minimize iatrogenic harm
nomenclature as well as an understanding of the physiology in the management of traumatic tension pneumothorax.
and clinical significance of the spectrum of pneumothoraces.
Finally, we conclude with the author group’s 16-point position Physiology
statement on traumatic tension pneumothorax, its definition
and management. Spontaneous ventilation is a process driven by negative pres-
sure produced by diaphragmatic and intercostal contraction.
The main author position is: This contraction increases the thoracic volume and thus gener-
• In spontaneously breathing tension pneumothorax, because ates a negative pressure within this space resulting in air move-
of the risk of harm, suspected low incidence, high rate of ment (down the pressure gradient) from the atmosphere into
misdiagnosis, and low rate of procedural success, a conser- the lung tissue (alveolar space). The pleural space is a potential
vative approach is advised. space that exists between the visceral pleura around the lung
• In positive pressure ventilated tension pneumothorax, the and the parietal pleura that lines the inside of the thoracic cav-
incidence is greater and the time to severe physiological im- ity. Physiologic pleural fluid exists between the visceral and
pact shorter; thus a more aggressive approach is advised. parietal pleura allowing the parietal lung surface to easily slide
*Correspondence to pat@atem.org.uk
Author bios are listed on page 64.
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