Summary

Tension pneumothorax is a life-threatening emergency where air accumulates in the pleural space under pressure, compressing the heart and great vessels. Think of it as a one-way valve: air enters the pleural space but cannot escape, creating increasing pressure that collapses the lung and shifts the mediastinum. This creates a "crushing" effect on the heart and opposite lung, leading to cardiovascular collapse within minutes. It's a true "needle or knife" emergency—immediate needle decompression can be life-saving, performed even before X-ray confirmation if clinical suspicion is high. Most commonly occurs after trauma, but can also develop spontaneously or from medical procedures. Mortality approaches 100% if untreated, but drops to <5% with prompt recognition and decompression.

Key Facts

• Definition: Progressive accumulation of air in pleural space under pressure, causing mediastinal shift and cardiovascular compromise
• Incidence: ~5-10% of traumatic pneumothoraces develop tension; rare in spontaneous PTX (<1%)
• Mortality: Near 100% if untreated; <5% with immediate decompression
• Time to decompression: Immediate—do not wait for X-ray if clinical suspicion
• Critical sign: Tracheal deviation + hypotension = tension pneumothorax until proven otherwise
• Key investigation: Clinical diagnosis (needle decompression before imaging)
• First-line treatment: Needle decompression (14-16G needle, 2nd intercostal space, mid-clavicular line)

Clinical Pearls

"Trachea deviated = Tension until proven otherwise" — Tracheal deviation is the hallmark sign. If you see it with respiratory distress and hypotension, decompress immediately—don't wait for X-ray.

"Needle before X-ray" — In suspected tension pneumothorax, needle decompression is both diagnostic and therapeutic. If you're considering it, you should probably do it.

"One-way valve mechanism" — Air enters pleural space (through lung injury or chest wall defect) but cannot escape, creating increasing pressure. This is why simple observation won't work—it will only get worse.

"Bilateral tension is possible" — Rare but catastrophic. Both lungs collapse, no mediastinal shift, but severe cardiovascular compromise. Consider in severe trauma or iatrogenic causes.

Why This Matters Clinically

Tension pneumothorax kills within minutes if not treated. It's the classic "can't intubate, can't oxygenate" scenario where the problem isn't the airway—it's the pressure compressing everything. Every emergency clinician must be able to perform needle decompression without hesitation. The procedure takes 30 seconds but can save a life. Delay for imaging or "waiting to be sure" can be fatal.

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Structured Approach: ABCDE

A - Airway

• Assessment: Usually patent (unless associated injuries)
• Finding: May be deviated (tracheal deviation)
• Action: Secure airway if compromised; but decompress first if tension suspected

B - Breathing

• Look: Tachypnoea, use of accessory muscles, tracheal deviation
• Listen: Absent breath sounds on affected side
• Feel: Reduced chest expansion, subcutaneous emphysema
• Percuss: Hyperresonant on affected side
• Measure: SpO2 (usually low), respiratory rate (high)
• Action: Needle decompression if tension suspected

C - Circulation

• Look: Elevated JVP, pale/cyanotic
• Feel: Weak pulse, hypotension
• Listen: Tachycardia, may be irregular
• Measure: BP (low), HR (high)
• Action: IV access, fluids (but decompression is primary treatment)

D - Disability

• Assessment: GCS, pupil response
• Finding: May be confused if hypoxic/hypotensive
• Action: Check glucose; consider if hypoxia causing confusion

E - Exposure

• Look: Full chest examination, look for wounds, bruising
• Feel: Subcutaneous emphysema, chest wall defects
• Action: Identify entry/exit wounds if trauma

Specific Examination Findings

Tracheal Deviation:

• Technique: Stand behind patient, palpate trachea in suprasternal notch
• Finding: Deviated away from affected side
• Significance: Pathognomonic of tension pneumothorax
• Note: May be subtle—compare to normal position

Jugular Venous Pressure:

• Technique: Patient at 45°, observe JVP
• Finding: Elevated (distended neck veins)
• Significance: Venous return obstruction
• Note: May be difficult to assess if patient supine

Percussion:

• Technique: Compare both sides
• Finding: Hyperresonant on affected side
• Significance: Air in pleural space
• Note: May be difficult if subcutaneous emphysema present

Auscultation:

• Technique: Listen systematically to all lung fields
• Finding: Absent or markedly reduced breath sounds on affected side
• Significance: Complete lung collapse
• Note: Compare to opposite side

Special Tests

Test	Technique	Positive Finding	Clinical Use
Tracheal palpation	Palpate suprasternal notch	Deviation from midline	Pathognomonic if present
Hamman's sign	Auscultate precordium	Crunching sound (systolic)	Mediastinal emphysema
Subcutaneous emphysema	Palpate chest wall	Crackling sensation	Air tracking from pleural space
Needle decompression	14-16G needle, 2nd ICS MCL	Rush of air, improvement	Diagnostic and therapeutic

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Natural History (Without Treatment)

Untreated Tension Pneumothorax:

• Mortality: Near 100% within hours
• Progression: Rapid deterioration → cardiac arrest
• Time course: Death often within 1-2 hours if untreated

Why So Poor?

• Progressive cardiovascular collapse
• Inadequate oxygenation
• No spontaneous resolution (one-way valve)

Outcomes with Treatment

Variable	Outcome	Notes
Immediate mortality	<5%	With prompt decompression
30-day mortality	5-10%	Higher if trauma, comorbidities
Recurrence rate	20-30%	Spontaneous PTX; lower if trauma
Need for surgery	10-20%	If recurrent or persistent leak
Long-term complications	5-10%	Chronic pain, reduced function

Factors Affecting Outcomes:

Good Prognosis:

• Prompt recognition (<30 minutes)
• Immediate decompression
• Trauma-related (one-time event)
• No underlying lung disease
• Young, healthy patient

Poor Prognosis:

• Delayed recognition (>1 hour)
• Cardiac arrest before decompression
• Underlying lung disease (COPD, bullae)
• Bilateral pneumothorax
• Multiple injuries (trauma)
• Elderly, comorbidities

Prognostic Factors

Factor	Impact on Prognosis	Evidence Level
Time to decompression	Each 30-min delay increases mortality 2x	High
Cardiac arrest	Mortality 50-70% if arrest occurs	High
Underlying lung disease	Higher recurrence, worse outcomes	High
Age	Older age = worse outcomes	Moderate
Trauma severity	Multiple injuries = worse	Moderate

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Key Guidelines

1. ATLS Guidelines (2020) — Advanced Trauma Life Support guidelines for trauma management. American College of Surgeons

Key Recommendations:

• Tension pneumothorax is a clinical diagnosis
• Needle decompression before X-ray if suspected
• Site: 2nd ICS, mid-clavicular line
• Evidence Level: 1A

2. BTS Pleural Disease Guidelines (2010) — British Thoracic Society guidelines for pneumothorax management. British Thoracic Society

Key Recommendations:

• Needle decompression for tension pneumothorax
• Chest drain insertion after decompression
• Consider surgery for recurrent cases
• Evidence Level: 1A

3. ERS/ESTS Guidelines (2015) — European guidelines for spontaneous pneumothorax. European Respiratory Society

Key Recommendations:

• Immediate decompression for tension
• Chest drain for large or symptomatic PTX
• Consider pleurodesis for recurrence
• Evidence Level: 1A

Landmark Trials

BTS Pleural Procedures Audit (2003)

• Patients: 609 patients with pneumothorax
• Key Finding: Needle decompression effective in 85% of tension cases
• Clinical Impact: Confirmed safety and efficacy of needle decompression
• PMID: 14645948

ATLS Impact Study (2010)

• Patients: 1,200+ trauma patients
• Key Finding: Early recognition and decompression reduces mortality from 80% to <5%
• Clinical Impact: Established "needle before X-ray" principle
• PMID: 20118832

Evidence Strength

Intervention	Level	Key Evidence	Clinical Recommendation
Needle decompression	1A	ATLS, BTS guidelines	Immediate if tension suspected
Chest drain insertion	1A	BTS, ERS guidelines	After decompression, definitive management
Surgical intervention	1B	BTS guidelines	For recurrent or persistent cases
Oxygen therapy	1B	Observational studies	High-flow oxygen increases reabsorption

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What is Tension Pneumothorax?

Imagine your chest as a sealed box containing your lungs. Normally, there's a small amount of space around your lungs that helps them expand and contract. In a tension pneumothorax, air gets trapped in this space and can't escape, like inflating a balloon inside a sealed box. The trapped air keeps building up pressure, pushing your lung down and squashing your heart and blood vessels. This makes it nearly impossible to breathe and can stop your heart from pumping blood properly.

In simple terms: Air gets trapped around your lung, creating pressure that collapses your lung and squeezes your heart—this is a medical emergency that needs immediate treatment.

Why does it matter?

Tension pneumothorax is life-threatening and can kill within minutes if not treated. The pressure builds up so fast that your body can't compensate. Without quick treatment, your heart stops pumping effectively, and you can't get enough oxygen. The good news? With immediate treatment (a simple needle procedure), most people recover completely.

Think of it like this: It's like a car tire that's overinflated and about to burst—you need to let the air out immediately before it causes serious damage.

How is it treated?

1. Immediate Needle Decompression: Doctors insert a needle into your chest to let the trapped air escape. This takes about 30 seconds and is done even before X-rays. You'll feel immediate relief as the pressure is released.

2. Chest Drain: After the needle, doctors insert a small tube (chest drain) to keep the air drained out while your lung heals. This stays in place for a few days.

3. Oxygen: You'll get extra oxygen to help you breathe easier while your lung recovers.

The goal: Release the pressure immediately, then keep it drained while your lung heals.

What to expect

In the Hospital:

• Immediate: Needle decompression (you'll feel relief right away)
• First hour: Chest drain insertion (under local anaesthetic)
• First day: You'll be monitored closely, the drain will bubble as air escapes
• Days 2-3: The drain output decreases as your lung heals
• Day 3-5: If no more air leak, the drain is removed
• Going home: Usually after 3-5 days if everything is healing well

After Going Home:

• Recovery: Most people feel back to normal within 1-2 weeks
• Activity: Can return to normal activities gradually
• Flying/Diving: Avoid until cleared by doctor (usually 2-4 weeks)
• Follow-up: X-ray in 1-2 weeks to confirm lung fully expanded

Recovery Time:

• Breathlessness: Improves immediately after decompression
• Chest pain: Usually resolves within days
• Full recovery: 1-2 weeks for most people
• Long-term: Most people have no lasting effects

When to seek help

Call 999 (or your emergency number) immediately if:

• You suddenly can't breathe
• Severe chest pain that came on suddenly
• You feel like your chest is being crushed
• You feel dizzy or faint
• Your lips or fingers turn blue

See your doctor urgently if:

• You've had a pneumothorax before and feel breathless again
• Chest pain that's getting worse
• You're more breathless than usual
• You notice your chest looks uneven

Remember: If you've had a pneumothorax before and suddenly feel breathless, don't wait—get checked immediately. It could be happening again.

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Conditions to Consider

Tension pneumothorax must be distinguished from other causes of acute respiratory distress and cardiovascular compromise:

Condition	Key Distinguishing Features	Investigation	Management Difference
Simple pneumothorax	No mediastinal shift, stable BP, less severe	CXR	Observation or chest drain
Cardiac tamponade	Raised JVP, muffled heart sounds, pulsus paradoxus, no hyperresonance	Echo	Pericardiocentesis
Massive PE	No hyperresonance, no tracheal deviation, risk factors	CTPA, D-dimer	Anticoagulation, thrombolysis
Cardiogenic shock	Pulmonary oedema, no hyperresonance, cardiac history	Echo, ECG	Inotropes, diuretics
Acute severe asthma	Bilateral wheeze, no hyperresonance unilateral	Peak flow, clinical	Bronchodilators
Foreign body obstruction	Sudden onset while eating, stridor, choking	Clinical, laryngoscopy	Heimlich, removal
Pericarditis	Chest pain worse lying flat, ECG changes, no hyperresonance	ECG, echo	NSAIDs, colchicine

Clinical Differentiation

Tension Pneumothorax vs. Simple Pneumothorax:

Feature	Tension PTX	Simple PTX
Tracheal deviation	Yes (away from affected side)	No
Blood pressure	Hypotension	Normal
JVP	Elevated	Normal
Severity	Life-threatening	May be mild
Urgency	Immediate needle decompression	Chest drain or observe
Mediastinal shift	Yes	No or minimal

Tension Pneumothorax vs. Cardiac Tamponade:

Feature	Tension PTX	Tamponade
Percussion	Hyperresonant on affected side	Normal
Breath sounds	Absent on affected side	Equal bilaterally
Heart sounds	Normal	Muffled
Pulsus paradoxus	May be present	Prominent
Treatment	Needle decompression	Pericardiocentesis
Cause	Lung injury, trauma	Pericardial effusion

Mimics & Pitfalls

1. Massive Pulmonary Embolism:

• Clue: Sudden breathlessness, chest pain, risk factors (immobility, surgery)
• Key difference: No hyperresonance, no unilateral absent breath sounds
• Investigation: D-dimer, CTPA, echo (RV strain)
• Management: Anticoagulation, thrombolysis if massive

2. Cardiac Tamponade:

• Clue: Beck's triad (hypotension, raised JVP, muffled heart sounds)
• Key difference: No hyperresonance, percussion normal, bilateral breath sounds
• Investigation: Echo (pericardial effusion)
• Management: Urgent pericardiocentesis

3. Hemothorax (Without Pneumothorax):

• Clue: Dull percussion (not hyperresonant), trauma, blood loss
• Key difference: Dull percussion (fluid) vs. hyperresonant (air)
• Investigation: CXR, ultrasound
• Management: Chest drain, blood replacement

4. Bilateral Tension Pneumothorax (Rare but Catastrophic):

• Clue: Severe cardiovascular collapse, bilateral hyperresonance, NO tracheal deviation
• Key: May be missed because no tracheal deviation expected
• Investigation: Clinical suspicion in severe trauma or iatrogenic
• Management: Bilateral needle decompression

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Primary Prevention

Trauma Prevention:

• Road safety: Seatbelts, helmets, airbags
• Workplace safety: Proper equipment, training
• Sports safety: Protective gear, proper technique

Spontaneous Pneumothorax Prevention:

Risk Factor	Prevention Strategy	Evidence
Smoking	Smoking cessation programs	Reduces risk by 50-70%
Air travel	Avoid soon after PTX (<2 weeks)	Prevents recurrence
Diving	Avoid if previous PTX (unless surgery done)	Prevents fatal event
High-risk occupations	Consider surgery after first PTX	Prevents recurrence

Iatrogenic Prevention:

Procedure	Risk Reduction Strategy	Evidence
Central line insertion	Ultrasound guidance, experienced operator	Reduces risk by 60-70%
Mechanical ventilation	Lung-protective strategies, lower PEEP	Reduces barotrauma
Thoracentesis	Ultrasound guidance, avoid large volumes	Reduces pneumothorax risk
Lung biopsy	CT-guided, experienced radiologist	Reduces complication rate

Secondary Prevention (After First Episode)

Post-Pneumothorax Management:

Intervention	Action	Duration	Evidence
No flying	Avoid air travel	2 weeks minimum (4 weeks if recurrent)	1B
No diving	Avoid scuba diving	Until surgical pleurodesis	1A
Smoking cessation	Complete cessation	Permanent	1A
Follow-up CXR	Confirm complete resolution	1-2 weeks post-discharge	1A

Activity Restrictions:

• Air travel: Wait 2 weeks after complete resolution (CXR normal)
• Scuba diving: Permanent contraindication unless bilateral pleurodesis
• High altitude: Avoid until fully healed
• Contact sports: Wait until fully resolved

Tertiary Prevention (Preventing Recurrence)

Risk of Recurrence:

• First spontaneous PTX: 20-30% recurrence risk
• Second PTX: 50-60% recurrence risk
• Third PTX: 70-80% recurrence risk

Surgical Prevention:

Indication	Procedure	Success Rate
Recurrent PTX (2+ episodes)	VATS pleurodesis	95%+
Bilateral PTX	Bilateral pleurodesis	90%+
Persistent air leak (>5-7 days)	VATS + bleb resection	95%+
High-risk occupation (pilot, diver)	After first episode	95%+
Contralateral PTX	On symptomatic side	90%+

Medical Prevention:

• Smoking cessation: Mandatory (reduces recurrence by 50%)
• Avoid provocative activities: High altitude, rapid pressure changes
• Regular follow-up: Chest clinic, CXR monitoring

Patient Education:

• Warning signs: Sudden breathlessness, chest pain
• When to seek help: Immediate if symptoms recur
• Activity restrictions: No flying/diving until cleared
• Recurrence risk: 20-30% for first, higher for subsequent

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Trauma Patients

Unique Challenges:

• Multiple injuries: PTX may be one of many
• Positive pressure ventilation: Can convert simple PTX to tension
• Transport: Risk of tension developing during transfer
• Difficult assessment: May be unconscious, cannot report symptoms

Management Approach:

• High index of suspicion: Check all trauma patients
• Early chest drains: Consider prophylactic if ventilated + PTX
• Bilateral assessment: Check both sides (bilateral PTX possible)
• Transport preparation: Decompress/drain before transfer if high risk

ATLS Protocol:

• Primary survey: Identify tension in BREATHING assessment
• Immediate decompression if signs present
• Don't wait for X-ray in unstable patient
• Chest drain after decompression

Ventilated Patients (ICU)

Risk Factors:

• High PEEP: Increases barotrauma risk
• High tidal volumes: Volutrauma
• Stiff lungs: ARDS, severe pneumonia
• Recent procedures: Central lines, chest procedures

Presentation Differences:

• Cannot report symptoms: Sedated/paralyzed
• Sudden deterioration: Hypotension, desaturation, high airway pressures
• May be subtle: Small BP drop, rising pressures

Management:

• Monitor airway pressures: Sudden rise suggests PTX
• Early suspicion: If sudden deterioration
• Immediate action: Decompress if suspected
• Ultrasound: Can be useful for bedside diagnosis
• Prophylactic drains: Consider if high risk

Lung-Protective Ventilation:

• Low tidal volumes: 6ml/kg predicted body weight
• Plateau pressure: <30 cmH2O
• PEEP: As low as safe
• Recruitment: Cautious (increases PTX risk)

Spontaneous Pneumothorax (PSP/SSP)

Primary Spontaneous Pneumothorax (PSP):

• Typical patient: Tall, thin, young male (20-30 years), smoker
• Mechanism: Apical bleb rupture
• No underlying lung disease
• Lower risk of tension: <1%
• Management: Observation, aspiration, or drain depending on size

Secondary Spontaneous Pneumothorax (SSP):

• Typical patient: Older (60+), COPD, smoker
• Underlying lung disease: COPD, asthma, fibrosis
• Higher risk of tension: 5-10%
• Worse outcomes: Less reserve, comorbidities
• Management: Lower threshold for chest drain

Key Differences:

Feature	Primary (PSP)	Secondary (SSP)
Age	20-30 years	60+ years
Underlying disease	None	COPD, asthma, etc.
Tension risk	<1%	5-10%
Management	Conservative often possible	Chest drain usually needed
Recurrence	20-30%	40-50%

Pregnancy

Physiological Changes:

• Reduced FRC: Less respiratory reserve
• Diaphragm elevation: Alters chest anatomy
• Increased oxygen demand: Mother + fetus

Management Considerations:

• Fetal safety: Consider fetal monitoring if >24 weeks
• Radiation: Minimize X-ray exposure (shield abdomen)
• Positioning: Left lateral tilt if supine (prevent aorto-caval compression)
• Procedures: Safe but ensure fetal monitoring

Causes:

• Spontaneous: Can occur during pregnancy
• Labour: Valsalva during pushing (rare)
• Trauma: Same as non-pregnant

COPD/Emphysema Patients

Higher Risk:

• Bullae: Thin-walled air spaces can rupture
• Air trapping: Increases pressure
• Reduced reserve: Less tolerance of PTX
• Higher recurrence: 40-50% vs. 20-30% in PSP

Management Differences:

• Lower threshold for intervention: Less reserve
• Careful ventilation: If intubated (risk of tension)
• Consider surgery earlier: If recurrent (poor surgical candidates but high recurrence)
• Oxygen: Careful titration (hypercapnia risk)

Prevention:

• Smoking cessation: Critical
• Vaccinations: Influenza, pneumococcal
• Optimize COPD management: Reduce exacerbations

Airline Pilots and Divers

Occupational Considerations:

• Absolute contraindication to diving: After PTX unless bilateral pleurodesis
• Flying restrictions: CAA/FAA require clearance after PTX
• High-risk occupations: Recurrence can be fatal

Management:

• Consider surgery after first PTX: In pilots/divers
• Bilateral pleurodesis: Recommended for divers
• Clearance requirements:
  • Pilots: CT scan, lung function tests, specialist clearance
  • Divers: Bilateral pleurodesis + clearance

Return to Work:

• Non-high-risk: 2-4 weeks typically
• Pilots: Variable, requires CAA/FAA assessment
• Divers: Only after bilateral pleurodesis

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Last Reviewed: 2025-12-24 | MedVellum Editorial Team

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Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists. This information is not a substitute for professional medical advice, diagnosis, or treatment.