Tension Pneumothorax Managed Without Immediate Needle Decompression
Stewart Siu Wa Chan, MBBS(Syd), FRCSEd, FHKAM (Emergency Medicine)
Stewart Siu Wa Chan, MBBS(Syd), FRCSEd, FHKAM (Emergency Medicine)
Abstract
Standard medical reference texts state that the immediate life-saving treatment for tension pneumothorax is needle decompression. This article reports a case of an 85-year-old man with tension pneumothorax who was managed without performing immediate needle decompression. Emergency physicians should be aware of the proper management of such cases.
There seems to be a growing body of evidence in the literature to suggest that in spontaneously breathing patients with tension pneumothorax, the rate of deterioration of this condition is much less rapid compared to ventilated patients, and the risks of performing needle decompression need to be balanced against the benefits of this procedure. In the absence of hemodynamic instability or severe respiratory insufficiency, the proper approach to managing such cases may be to carefully monitor the patient, promptly obtain portable chest radiography, and immediately perform chest tube drainage once the diagnosis is confirmed.
Standard medical reference texts state that the immediate life-saving treatment for tension pneumothorax is needle decompression. This article reports a case of an 85-year-old man with tension pneumothorax who was managed without performing immediate needle decompression. Emergency physicians should be aware of the proper management of such cases.
There seems to be a growing body of evidence in the literature to suggest that in spontaneously breathing patients with tension pneumothorax, the rate of deterioration of this condition is much less rapid compared to ventilated patients, and the risks of performing needle decompression need to be balanced against the benefits of this procedure. In the absence of hemodynamic instability or severe respiratory insufficiency, the proper approach to managing such cases may be to carefully monitor the patient, promptly obtain portable chest radiography, and immediately perform chest tube drainage once the diagnosis is confirmed.
Introduction
Tension pneumothorax is a well-known life-threatening condition and it has long been taught that emergency treatment involves immediate needle decompression. However, the literature has numerous reports of the shortcomings or failure of this modality of treatment.[1-6] There are also at least three case reports describing patients with tension pneumothorax managed successfully by chest tube drainage, without performing immediate needle decompression.[7-9] There seem to be certain clinical situations in which immediate chest tube drainage may be a better option than needle decompression for the management of tension pneumothorax.
Although standard medical textbooks and expert authorities correctly emphasize careful clinical diagnosis and the indications for immediate needle decompression, most fail to mention how to manage a subset of lower-risk cases of pneumothorax in which tension is thought to exist but needle decompression may not be a necessary immediate step.[10-15] Hence, emergency physicians encountering such situations may be faced with a dilemma in the choice of treatment. Leigh-Smith and Harris have addressed this issue in a recent extensive review of literature, and they urge that it is time physicians have a "re-think".[4] The following case report is illustrative of a typical scenario.
Case Report
An 85-year-old man was brought to the Emergency Department by ambulance complaining of shortness of breath. Paramedics detected his oxygen saturation at home on room air to be 79% and he was given oxygen therapy. On arrival, hisheart rate was 127 beats/min, blood pressure 149/75 mm Hg, temperature 38.9°C, respiratory rate 22 breaths/min, and oxygen saturation 94% on 3 L/min oxygen, and he was fully conscious.
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Tension pneumothorax is a well-known life-threatening condition and it has long been taught that emergency treatment involves immediate needle decompression. However, the literature has numerous reports of the shortcomings or failure of this modality of treatment.[1-6] There are also at least three case reports describing patients with tension pneumothorax managed successfully by chest tube drainage, without performing immediate needle decompression.[7-9] There seem to be certain clinical situations in which immediate chest tube drainage may be a better option than needle decompression for the management of tension pneumothorax.
Although standard medical textbooks and expert authorities correctly emphasize careful clinical diagnosis and the indications for immediate needle decompression, most fail to mention how to manage a subset of lower-risk cases of pneumothorax in which tension is thought to exist but needle decompression may not be a necessary immediate step.[10-15] Hence, emergency physicians encountering such situations may be faced with a dilemma in the choice of treatment. Leigh-Smith and Harris have addressed this issue in a recent extensive review of literature, and they urge that it is time physicians have a "re-think".[4] The following case report is illustrative of a typical scenario.
Case Report
An 85-year-old man was brought to the Emergency Department by ambulance complaining of shortness of breath. Paramedics detected his oxygen saturation at home on room air to be 79% and he was given oxygen therapy. On arrival, hisheart rate was 127 beats/min, blood pressure 149/75 mm Hg, temperature 38.9°C, respiratory rate 22 breaths/min, and oxygen saturation 94% on 3 L/min oxygen, and he was fully conscious.
DOWNLOAD PDF COMPLETE HERE
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