Tension Pneumothorax: Etiology, Diagnosis, Pathophysiology, and Management

Abstract

Gilbert TB, XlcGrath BJ. Tension pneumothoras: etiology, diagnosis, pathophysiology, and management. J Intensive Care Ned 1994;93139-150.The normally air-free pleural cavity exists at subatmospheric pressure to promote pleural apposition and proper lung excursion. Owing to its unique bilayer structure, air introduced into this space either from within the thoracic cavity or from an extrathoracic source causes pleural separation and simple pneuniothorax (FTX). Most simple pneumothoracies of a small or static volume in healthy patients d o not appreciably impair cardiopulmonary function despite variable collapse of the lung. If increasing pressure develops within this pleural air collection, however, a cascade of pathophysiological changes can result from altered anatomical positions of heart, lung, and great vessels. The development of increasini pressure within the pleural space. with resultant ipsilateral lung collapse and hemithoracic expansion into the mediastinum and the contralateral lung, is termed tension pnenmothornu (TPTX). The exact incidence of TPTX is unknown, but it is reported in up to 2 to 3% of all pneumothoracies. Certain medical and surgical disease states-many found within the critical care environment-place patients at higher risk for development of TPTX and also limit physiological tolerance to TPTX once it occurs. Althoughphysical examinationand chest ndiography generally confirm the occurrence of TPTX, physiological monitoring may herald the development of increasing intrapleural pressure. Expeditious recognition and pleural decompression are necessary to prevent the untoward hemodynamic and respiratory consequences of TPTX. Significant morbidity and mortality may arise from TPTX if treatment is unduly delayed, particularly in mechanically ventilated patients.From the Each lung is wrapped by a closed invaginated sac-the pleura-a delicate bilayered serous membrane (Fig 1). Right and left sides in humans are completely separated by the bulk of the mediastinum. The pleura extends superiorly beyond the confines of the t h o r n into the base of the neck as the cupula. Inferiorly, it courses in tandem with the lung and diaphragm with an excursion between the two. On the right, it crosses the midzxillary line at the tenth rib, ending posterior to the spinous process of the twelfth rib. On the left, it courses slightly more inferiorly [I]. Thus, injury to the upper abdomen or neck can violate the pleura as well as injury throughout the entire thoracic cage. The portion of pleura that envelops the surface of the lung and invaginates the interlobar fissures is termed the u&-can1 pleim-a. The remaining membrane that lines the inner chest wall, the diaphragm, and the medial mediastinum is termed the parietalplera-a.A potential space containing a small amount of fluid exists between the contiguous pleural layers. Lung tissue acts as an interface between air-laden bronchoalveolar passages and the air-free pleural space, Intrapleural pressure varies from -3 to -5 mm Hg during inspiration and -5 to -10 mm...

Occult tension pneumothorax discovered following imaging for adult trauma patients in the modern major trauma system: a multicentre observational study

“…It has been reported that patients who have been intubated and ventilated are at higher risk of developing simple or tension pneumothorax due to iatrogenic barotrauma,13 19–21 and there is a significant risk of death if there is any delay in subsequent treatment 22. This may be one factor that played a part in the decision-making in the current study, with intubated patients being more likely to be diagnosed and managed clinically rather than investigated by CXR and CT.…”

Multiple Rare Complications Following Total Thyroidectomy and Bilateral Neck Dissection: Case Report and Literature Review

“…mask and an Ambu bag for 5 to 10 minutes before he was re-intubated and ventilated. Acute bronchospasm and tension pneumothorax during general anesthesia are uncommon, however it has to be suspected and immediately managed by taking a stat chest X-ray, especially if the patient shows signs of respiratory insufficiency even in the presence of other complications which appear to account for the respiratory distress like in our patient where total thyroidectomy and bilateral neck dissection are more commonly complicated by respiratory distress, stridor or even pneumomediastinum and bilateral pneumothorax [9][10][11][12]. Such complications if overlooked or left untreated untoward hemodynamic and respiratory after effects will ensue.…”

“…Such complications if overlooked or left untreated untoward hemodynamic and respiratory after effects will ensue. Delay in the treatment of tension pneumothorax can result in significant morbidity and mortality particularly in mechanically ventilated patients [10]. On the other hand unilateral spontaneous pneumothorax is a common finding in a wide spectrum of patients; bilateral spontaneous pneumothorax is estimated to account for only 1.3% of all cases of pneumothorax [11].…”

Clinical manifestations of tension pneumothorax: protocol for a systematic review and meta-analysis

“…To our knowledge, only six non-systematic or narrative reviews on tension pneumothorax have been published between the years 1956 and 2013 [1,7,13,14,28,29], and only two of these [1,7] suggested that the clinical manifestations of tension pneumothorax may differ according to the respiratory status of the patient. The absence of a systematic review on this topic may relate to the perceived lack of relevant observational data given that tension pneumothorax is difficult to study (given that it presents acutely, is relatively uncommon and life-threatening, and requires immediate treatment).…”

“…While the above suggested differences in clinical manifestations among patients with a tension pneumothorax may have clinical importance, they remain largely based on narrative or non-systematic syntheses of the available clinical data and therefore could be accounted for by selection bias [ 1 , 7 ]. To our knowledge, only six non-systematic or narrative reviews on tension pneumothorax have been published between the years 1956 and 2013 [ 1 , 7 , 13 , 14 , 28 , 29 ], and only two of these [ 1 , 7 ] suggested that the clinical manifestations of tension pneumothorax may differ according to the respiratory status of the patient. The absence of a systematic review on this topic may relate to the perceived lack of relevant observational data given that tension pneumothorax is difficult to study (given that it presents acutely, is relatively uncommon and life-threatening, and requires immediate treatment).…”