Page 61 - JSOM Winter 2024

positive pressure ventilated patients, elevated peak inspiratory thoracostomy, a collapsed lung (“lung down”) can be palpated.
pressures also suggest the presence of tension pneumothorax. If the provider has experience and is aware of how an expanded
lung feels on palpation, then it is easy to identify the collapsed
In their article “Tension pneumothorax—time for a re-think?” lung. It is the absence of the lung that is palpated. This is com-
Leigh-Smith et al. distinguished between awake (spontaneously mon practice and terminology in finger thoracostomy.
5
breathing) and (positive pressure ventilated) patients. The au-
thors of the current paper agree with Leigh-Smith et al.’s ap- Evidence suggests that the failure rate in diagnosing tension
proach, which is outlined in tables 1–5. Tension pneumothorax pneumothorax is high, with one retrospective CT study show-
is the same disease process, but in positive pressure ventilated pa- ing a misdiagnosis rate of 39%. 7
tients, respiratory symptoms are masked and circulatory effects
exacerbated, thus this single pathology has two presentations. In spontaneously breathing patients, tension pneumothorax
is thought to be rare and manifests as worsening respiratory
TABLE 1 Signs and Symptoms of Tension Pneumothorax in compromise with eventual circulatory collapse. In positive
Spontaneously Breathing (Awake) Tension Pneumothorax Patients 5 pressure ventilated patients the risk and incidence of tension
Universal findings • Chest pain pneumothorax is higher. This process may develop rapidly and
• Respiratory distress presents as circulatory compromise (shock) leading to cardiac
Common findings In 50%–75% of cases: arrest if left untreated.
• Tachycardia
• Ipsilateral decreased air entry
Inconsistent In <25% of cases: While the statement that tension pneumothorax manifests as
findings • Low SpO 2 respiratory compromise in the spontaneously breathing pa-
• Tracheal deviation tients and circulatory compromise in positive pressure venti-
• Hypotension lated patients may seem to be a departure from conventional
Rare findings • Cyanosis thinking on this topic, it is merely a refinement. There is in fact
(about 10% of • Hyper-resonance no adoption of a different fundamental pathology; it is merely
cases) • Decreasing level of consciousness a realization that positive pressure ventilation masks the signs
• Ipsilateral chest:
ο Hyper-expansion and symptoms of respiratory failure.
ο Hypo-mobility
• Acute epigastric pain The most common presentations of tension pneumothorax are
• Cardiac apical displacement listed in Table 2.
• Sternal resonance
SpO = oxygen saturation. TABLE 3 Diagnosis of Tension Pneumothorax in Spontaneously
2
Breathing (Awake) Patients 5
TABLE 2 Signs and Symptoms of Tension Pneumothorax in Positive Progression Rapid disease progression
Pressure Ventilated Patients from Case Reports 5
Reliable early signs • Pleuritic chest pain
Universal findings • Rapid onset • Air hunger
• Immediate and progressive decrease in • Respiratory distress
arterial and mixed venous SpO 2 • Tachypnoea
• Immediate reduction in cardiac output • Tachycardia
± BP • Falling SpO 2
Common findings Each in about 33% of cases: • Agitation
• High ventilation pressures Disease lateralization
• Ipsilateral chest: Ipsilateral • Hyper-expansion
ο Hyper-expansion • Hypo-mobility
ο Hypo-mobility • Hyper-resonance
ο Decreased air entry • Decreased breath sounds
Inconsistent Each in about 20% of cases: • Added sounds – crackles/wheeze
findings • Surgical emphysema Contralateral • Hyper-mobility
• Venous distension
BP = blood pressure; SpO = oxygen saturation. Other signs
2
Pre-terminal • Decreasing respiratory rate
Radiographic Imaging • Hypotension
• Decreasing SpO
Visceral and parietal pleural separation, diaphragmatic de- • Decreasing level of consciousness
2
pression, mediastinal shift, expanding pneumothorax on se- Inconsistent • Tracheal deviation
rial imaging, presence of pneumothorax on radiograph in the • Distended neck veins
mechanically ventilated patient, extra-thoracic subcutaneous SpO = oxygen saturation.
air, and mediastinal shift on chest radiograph suggests tension 2
pneumothorax or high risk for tension pneumothorax. 6 It is essential to identify the side affected by the tension pneu-
mothorax, as this is crucial for treatment. In the absence of
Findings on Intervention ultrasound, the most reliable tool for the identification of the
In tension pneumothorax, improvement in hemodynamics, affected side is a physical examination and the character of
respiratory status and/or ventilator changes or patient relief breath sounds on auscultation, percussion, and palpation of
are the most prominent findings with successful chest decom- chest wall expansion.
pression. A useful addition in diagnosis is the observation of
bubbles in a fluid-filled syringe on aspiration during needle Ultrasound in Diagnosis
decompression (NDC). The commonly described hiss of air is Point-of-care ultrasound in trauma is gaining traction since
very environment-dependent and variably observed. On finger the formalization of the focused assessment with sonography

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