What Is Pneumothorax?
Pneumothorax is a condition that occurs when air accumulates in the pleural space or the tissue lining of the lungs. The pleura is a double-layered membrane lining the inner layer of the chest wall and the lung surface, making it feasible for them to move and slide together during respiration. Both the layers of the pleura fold onto each other, forming the pleural space. Usually, the space between the pleura consists of a thin layer of fluid that prevents the two layers from rubbing against each other.
The air accumulated in the pleural space puts pressure on the lungs, further leading to their collapse. Pneumothorax can be traumatic or atraumatic. Traumatic pneumothorax occurs secondary to a penetrating injury, blunt trauma, or medically induced (iatrogenic). Iatrogenic pneumothorax is a traumatic condition due to air accumulating into the pleural cavity due to medical intervention procedures. Atraumatic pneumothorax is further divided into:
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Primary Pneumothorax - Pneumothorax with an unknown cause.
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Secondary Pneumothorax - A person with underlying lung disease.
Pneumothorax is further classified as:
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Simple Pneumothorax - The pneumothorax wherein there is no shift of the associated structures.
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Tension Pneumothorax - In this, there is a shift in the structures around the lungs.
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Open Pneumothorax - The air passes through an open chest wound in this condition.
What Is Tension Pneumothorax?
Tension pneumothorax is a life-threatening condition that results when air gets entrapped within pleural space around the lungs, compressing the lungs, heart, blood vessels, and other structures and leading to impaired cardiopulmonary function. Both traumatic and tension pneumothoraces are life-threatening conditions requiring immediate treatment. When there is pleural damage due to an underlying lung disease or trauma to the chest cavity, air can flow into the pleural space but cannot exit. This trapped air within the pleural space puts pressure on the lungs and prevents them from expanding accordingly, thus causing respiratory distress. In addition, the trapped air displaces the windpipe and other structures around the lungs leading to breathing problems. The raised chest pressure can further compress the heart blood vessels leading to a cardiovascular collapse.
What Are the Symptoms of Tension Pneumothorax?
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Shortness of breath.
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Chest pain.
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Shallow breathing.
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Low levels of oxygen in the blood.
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Low blood pressure.
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Increased heart rate.
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Confusion.
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Tachypnea(fast breathing).
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Bluish discoloration of the skin.
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Prominent and distended neck veins.
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Pneumomediastinum - This condition is where the air gets trapped in the space in the chest between the lungs.
How Is Tension Pneumothorax Diagnosed?
If the individual is unstable, a bedside ultrasound should be performed. Whereas in a stable individual, a chest X-ray is used to confirm the diagnosis. If the result is unclear in a chest X-ray, a chest C.T. (computed tomography) scan can be done.
How Is Tension Pneumothorax Treated in an Emergency?
Tension pneumothorax is managed in the emergency department or the I.C.U. (intensive care unit). The management of tension pneumothorax depends on the condition of the individual. The airway, breathing, and circulation should be evaluated if the person complains of chest injury. The penetrating chest injuries should be covered with an airtight bandage. 100 percent of supplemental oxygen should be administered to help reduce the size of the pneumothorax. Only 1.25 percent of the air is absorbed without oxygen in a day. In the beginning, positive pressure ventilation should be avoided, as it will increase the size of tension pneumothorax. A chest tube is placed in the individual, after which they are placed on positive pressure ventilation.
If the individual is unstable, immediate needle decompression must be performed without delay. Needle decompression, also known as needle thoracostomy, relieves the trapped air from within the pleural space. During the procedure of needle decompression, the physician inserts a large needle through the chest wall, between the ribs, and into the pleural cavity space. It leads to the re-expansion of the collapsed lungs. If the re-expansion occurs quickly, it increases the risk of pulmonary edema. After the needle decompression, a chest tube is placed in the individual, and a chest X-ray is carried out to evaluate the resolution of tension pneumothorax. This procedure can be life-saving, especially in the prehospital setting, as transport to the hospital can delay treatment.
The chest tubes are handled by experienced nurses, respiratory therapists, surgeons, and I.C.U. physicians. In most cases, a chest tube is sufficient; however, surgery is required in a few cases. The surgery could either be video-assisted thoracoscopic surgery (VATS) or thoracotomy. Individuals requiring surgical intervention are those with pneumothorax in both the lungs, recurring pneumothorax, high-risk professionals like pilots and drivers, and people with continuous air leakage for more than a week.
In video-assisted thoracic surgery (VATS), pneumothorax is treated with pleurodesis. Pleurodesis is a procedure in which a mild irritating drug is placed into the pleural space on one part of the chest to prevent further accumulation of air in the space. Pleurodesis is of two kinds: mechanical and chemical.
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Mechanical Pleurodesis - With this, there are significantly fewer chances of recurrence of pneumothorax. This includes abrasive scratchpad, dry gauze, or stripping of the parietal pleura.
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Chemical Pleurodesis - This includes talc, Minocycline, Doxycycline, or Tetracycline. Chemical pleurodesis is performed if the individual is unable to tolerate mechanical pleurodesis. Recent studies have found that pleurodesis can reduce the appearance of recurrence.
Conclusion:
Tension pneumothorax is a life-threatening condition that should be immediately treated before it becomes fatal. It can be associated with either a closed or open chest injury. A delay in prompt diagnosis and management leads to a poor prognosis. Tension pneumothorax is caused by various factors and can rapidly progress to respiratory insufficiency, cardiovascular collapse, and death if not treated early. Uncomplicated pneumothorax can recur within six months to three years and are more common in smokers, COPD, and H.I.V. (human immunodeficiency virus) patients. After tension pneumothorax, the individual should avoid air travel until complete resolution or for a minimum of two weeks after surgery. High-risk professionals like scuba divers and pilots should not dive or fly until complete resolution of the condition by pleurodesis or thoracotomy. Individuals should quit smoking. Good evaluation skills, proper equipment, and the proper training to effectively relieve a tension pneumothorax are essential to save people from this critical condition.
