Pneumothorax

Overview

Tension pneumothorax is a clinical diagnosis - do NOT wait for imaging. A one-way valve mechanism causes progressive air accumulation, mediastinal shift, impaired venous return, and cardiovascular collapse.

•Tracheal deviation - away from affected side (late sign)

•Absent breath sounds + hyperresonance - ipsilateral

•Cardiovascular collapse - hypotension, tachycardia, raised JVP

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Suspected tension pneumothorax requires immediate needle thoracostomy - do not delay for chest X-ray, ABG, or IV fluids. Chest drain follows after initial decompression.

Management of Tension Pneumothorax

•Immediate: needle thoracostomy - 2nd intercostal space, mid-clavicular line on affected side; decompresses pleural space

•Definitive: chest drain insertion - after initial needle decompression

Investigations (Non-tension Pneumothorax Only)

🥇 First-line

•chest X-ray (PA, erect) - visible lung edge with absent peripheral lung markings; small <2 cm rim at hilum, large ≥2 cm rim

🥈 Second-line

•CT chest - gold standard for size, underlying bullae, distinguishing from giant bulla

•Tension CXR findings (if obtained after decompression): complete ipsilateral collapse, contralateral mediastinal shift, ipsilateral diaphragm depression

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In tension pneumothorax, treatment must not be delayed for any investigation - the diagnosis is clinical.