A.J. McCarthy, age 26, is admitted to the emergency department (ED) with a right tibia-fibula fracture sustained in an all-terrain vehicle accident. While awaiting an orthopedic consult, he is admitted to the medical-surgical unit, where Patricia, his nurse, obtains the following vital signs: blood pressure (BP) 124/62 mm Hg, heart rate (HR) 78 beats/minute (bpm), respiratory rate (RR) 18 breaths/minute, temperature 98.4° F (36.9° C), and oxygen saturation (O₂ sat) 99% on room air.

History and assessment hints

Patricia’s assessment reveals multiple bruises and abrasions on the right side of his body, including the thorax. A.J. reports the pain medication he received in the ED decreased his pain.

When Patricia checks on A.J. 1 hour later, she notes RR is 24 breaths/minute, his O₂ sat is 93%, and his breath sounds are slightly diminished on the right. Per standing orders, she administers oxygen at 2 L/ minute via nasal cannula and monitor his status.

Thirty minutes later, A.J. reports increased shortness of breath and sharp right-sided chest pain. Patricia finds his RR is now 36 breaths/minute and his O₂ sat is 87%. Equally alarming, his BP is 130/80 mm Hg and his HR is 125 bpm. She immediately calls the rapid response team (RRT) and applies a nonrebreather oxygen mask.

On the scene

On arrival, the RRT physician diagnoses tension pneumothorax based on physical findings. She directs Patricia to prepare for needle decompression of the pneumothorax as well as chest-tube insertion, explaining that decompression shouldn’t be delayed for chest X-ray confirmation of a tension pneumothorax. The physician inserts the needle in the second intercostal space at the midclavicular line and advances it until a hissing sound occurs, indicating release of air pressure from the pleural space.

The RRT readies the thoracostomy tray for chesttube insertion while Patricia prepares the closed waterseal chest-drainage system. Immediately after chesttube insertion, the physician orders a chest X-ray to confirm correct tube placement and pneumothorax status. With successful decompression, A.J.’s respiratory distress decreases. Patricia continues to monitor his vital signs, pain level, lung sounds, breathing pattern, O₂ sat, chest-tube patency and dressing, and integrity and position of the chest-drainage system. She also palpates his chest to check for subcutaneous emphysema.

Outcome

A.J.’s chest X-ray shows proper tube placement and a resolving right tension pneumothorax. He is transferred to the step-down unit. After 2 days, an X-ray shows his right lung is fully reinflated and the chest-drainage system has no visible air leak. Lung reinflation remains stable with the drainage system on water-seal. The physician removes the chest tube and A.J.’s remaining hospital stay is uneventful.

Education and follow-up

In tension pneumothorax, air enters the pleural space, causing trapping of air on expiration, lung collapse, and displacement of the trachea and mediastinal structures to the opposite side. Without early recognition and prompt treatment, it can lead to cardiac compromise and respiratory and cardiac arrest.

In patients who aren’t on mechanical ventilation, tension pneumothorax is linked to penetrating and blunt force trauma or failed central venous catheter insertion. These patients typically have chest pain, hypoxia, progressive respiratory distress, and increased oxygen requirements with slower symptom evolution; hemodynamic compromise is a late sign. In contrast, patients on assisted ventilation are likely to experience hypotension and cardiac arrest evolving over minutes from the time of injury.

Early diagnosis in patients with unassisted breathing rests on respiratory manifestations. Patricia’s recognition of A.J.’s respiratory symptoms helped ensure her patient got the lifesaving treatment he needed.

Amy Shay is an assistant professor at Indiana University–Purdue University Indianapolis School of Nursing and an Alumnus CCRN.

Selected references

MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65 Suppl 2:ii18-31.

Noppen M. Spontaneous pneumothorax: Epidemiology, pathophysiology and cause. Eur Respir Rev. 2010;19(117):217-9.

Roberts DJ, Leigh-Smith S, Faris PD, et al. Clinical manifestations of tension pneumothorax: Protocol for a systematic review and meta-analysis. Syst Rev. 2014;3:3.

Roberts DJ, Leigh-Smith S, Faris PD, et al. Clinical presentation of patients with tension pneumothorax: A systematic review. Ann Surg. 2015;261(6):1068-78.

Wagner KD, Hardin-Pearce MG. High-Acuity Nursing. 6^th ed. Upper Saddle River, NJ: Pearson; 2013.

Wernick B, Hon HH, Mubang RN, et al. Complications of needle thoracostomy: A comprehensive clinical review. Int J Crit Illn Inj Sci. 2015;5(3):160-9.