11/13/24, 7\:38 PM Guide | Pneumothorax
Pneumothorax
Table of contents
Introduction
This guide provides an overview of the recognition and immediate management of pneumothorax using an ABCDE
approach.
The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working
through the following steps\:
Airway
Breathing
Circulation
Disability
Exposure
Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed
as they are identi
This guide has been created to assist students in preparing for emergency simulation sessions as part of their training, it is not
intended to be relied upon for patient care.
Clinical features
A pneumothorax is a collection of air between the parietal and visceral pleura of the lung. There are several di
classify and name pneumothoraces.
Pneumothoracies can be classi
A primary pneumothorax develops in the absence of an underlying disease process.
A secondary pneumothorax develops as a result of underlying lung disease such as asthma or COPD.
Pneumothoraces can also be described as spontaneous or traumatic (e.g. occurring secondary to penetrating chest trauma).
Tension pneumothorax
All types of pneumothorax can potentially develop into a tension pneumothorax.
A tension pneumothorax is a medical emergency due to the resulting sudden rise in intrathoracic pressure which reduces
venous return to the heart and ultimately causes cardiac arrest if left untreated.
Symptoms
Typical symptoms of a pneumothorax include\:
Sudden onset chest pain
Acute shortness of breath
A feeling of not being able to take a full breath
Signs
Typical clinical signs of a pneumothorax include\:
Tachypnoea
Tachycardia
Hypoxia
Reduced breath sounds on the a
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Hyperresonance on the a
Tracheal deviation away from the a
treatment with decompression.
Tips before you begin
General tips for applying an ABCDE approach in an emergency setting include\:
Treat all problems as you discover them.
Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
Make use of the team around you by delegating tasks where appropriate.
All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
Clearly communicate how often would you like the patient’s observations relayed to you by other sta
If you require senior input, call for help early using an appropriate SBARR handover structure.
Review results as they become available (e.g. laboratory investigations).
Make use of your local guidelines and algorithms in managing speciacute asthma).
Any medications or will need to be prescribed at the time (in some cases you may be able to delegate this to another
member of sta
Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical
assessment, investigations and interventions.
Initial steps
Acute scenarios typically begin with a brief handover from a member of the nursing sta
name, age, background and the reason the review has been requested.
You may be asked to review a patient with pneumothorax due to shortness of breath and/or chest pain.
Introduction
Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.
Interaction
Introduce yourself to the patient including your name and role.
Ask how the patient is feeling as this may provide some useful information about their current symptoms.
Preparation
Make sure the patient’s notes, observation chart and prescription chart are easily accessible.
Ask for another clinical member of sta
If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.
Airway
Clinical assessment
Can the patient talk?
Yes\: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.
No\:
Look for signs of airway compromise\: these include cyanosis, see-saw breathing, use of accessory muscles, diminished
breath sounds and added sounds.
Open the mouth and inspect\: look for anything obstructing the airway such as secretions or a foreign object.
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Causes of airway compromise
There is a wide range of possible causes of airway compromise including\:
Inhaled foreign body\: symptoms may include sudden onset shortness of breath and stridor.
Blood in the airway\: causes include epistaxis, haematemesis and trauma.
Vomit/secretions in the airway\: causes include alcohol intoxication, head trauma and dysphagia.
Soft tissue swelling\: causes include anaphylaxis and infection (e.g. quinsy, necrotising fasciitis).
Local mass e
Laryngospasm\: causes include asthma, gastro-oesophageal re
Depressed level of consciousness\: causes include opioid overdose, head injury and stroke.
Interventions
Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the
emergency medical team (often referred to as the 'crash team'). In the meantime, you can perform some basic airway
manoeuvres to help maintain the airway whilst awaiting senior input.
Head-tilt chin-lift manoeuvre
Open the patient's airway using a head-tilt chin-lift manoeuvre\:
1. Place one hand on the patient’s forehead and the other under the chin.
2. Tilt the forehead back whilst lifting the chin forwards to extend the neck.
3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a
remove it.
Jaw thrust
If the patient is suspected to have su
than a head-tilt chin-lift manoeuvre\:
1. Identify the angle of the mandible.
2. With your index and other
lift the mandible.
3. Using your thumbs, slightly open the mouth by downward displacement of the chin.
Oropharyngeal airway (Guedel)
Airway adjuncts are often helpful and in some cases essential to maintain a patient's airway. They should be used in
conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the
airway aligned.
An oropharyngeal airway is a curved plastic tube with a
relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may
induce gagging and aspiration.
To insert an oropharyngeal airway\:
1. Open the patient's mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is
present, attempt removal using suction.
2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which
point you should rotate it 180°
. The reason for inserting the airway upside down initially is to reduce the risk of pushing the
tongue backwards and worsening airway obstruction.
3. Advance the airway until it lies within the pharynx.
4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient's airway by looking, listening and feeling for
signs of breathing.
Nasopharyngeal airway (NPA)
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A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a
tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients
who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the
NPA.
To insert a nasopharyngeal airway\:
1. Check the patency of the patient's right nostril and if required (depending on the model of NPA) insert a safety pin through
the
2. Lubricate the NPA.
3. Insert the airway bevel-end
4. If any obstruction is encountered, remove the tube and try the left nostril.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Breathing
Clinical assessment
Observations
Review the patient’s respiratory rate\:
A normal respiratory rate is between 12-20 breaths per minute.
Tachypnoea is a common feature of pneumothorax and indicates signi
Bradypnoea in the context of hypoxia is a sign of impending respiratory failure and the need for urgent critical care review.
Review the patient’s oxygen saturation (SpO )\:
2
A normal SpO 2
range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk
of CO retention.
2
See our guide to performing observations/vital signs for more details.
Examination
Auscultate, palpate and percuss the patient's lungs
Typical clinical
Unilaterally reduced chest expansion
Unilateral hyper-resonance
Unilaterally reduced air entry
A tension pneumothorax is a clinical diagnosis.
Treat for a tension pneumothorax immediately, without waiting for a chest X-ray, if you
above) in addition to\:
Tracheal deviation
Raised jugular venous pressure (JVP)
Investigations
Arterial blood gas
Take an ABG if indicated (e.g. low SpO ) to quantify the degree of hypoxia.
2
Typical ABG 2 2 2
and low PaCO (due to hyperventilation). A normal or raised PaCO is
concerning as it indicates that the patient is tiring and failing to ventilate e
Chest X-ray
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A chest X-ray will identify most pneumothoraces.
Typical chest X-ray
Air in the pleural space
Decreased lung markings around the outer edge of the lung
Lung collapse
Small pneumothoraxes can be di
A chest X-ray showing a tension pneumothorax should ideally never be seen, as the diagnosis should have been clinically and
treated immediately. If, however, a chest X-ray was performed, you would expect to see visible tracheal deviation, mediastinal
shift and lung collapse.
A chest X-ray is also useful when trying to rule out other respiratory diagnoses (e.g. pneumonia, pulmonary oedema). Chest X-
ray should not delay the emergency management of tension pneumothorax.
Interventions
Oxygen
Administer oxygen to all critically unwell patients during your initial assessment. This typically involves the use of a non-
rebreathe mask with an oxygen
assessment.
If the patient is conscious, sit them upright as this can also help with oxygenation.
Management of simple pneumothorax
There are very clear guidelines from the British Thoracic Society (BTS) on how to treat pneumothorax.
1
Management di
If the patient has a history of smoking or underlying lung disease (more likely to have a secondary pneumothorax)
Age of the patient
Size of the pneumothorax
Degree of breathlessness
Response to treatment
Management options
Consider discharge and review in 2-4 weeks\: this is for patients with a small primary pneumothorax and no breathlessness.
Aspirate with a 16-18G cannula (up to 2.5L)\:
Patients with a large primary pneumothorax
Symptomatic patients
Patients with a small secondary pneumothorax
Admit and administer high
Patients with a small (\<1cm) secondary pneumothorax
Patients who have undergone aspiration of the air
Chest drain insertion and admission\:
Patients who have not improved following aspiration
Patients with large secondary pneumothoraces
Management of tension pneumothorax
Tension pneumothorax requires immediate treatment with needle decompression.
Needle decompression involves placing a needle or cannula into the 2 nd
a
intercostal space, mid-clavicular line (on the
A chest drain can then be inserted once the initial decompression has been performed.
If you think you are dealing with a tension pneumothorax you should ask someone to put out a peri-arrest call on 2222.
CPR
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If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Circulation
Clinical assessment
Pulse
Patients with pneumothorax may be tachycardic due to pain, anxiety or reduced oxygen saturation.
Bradycardia is a late sign of a tension pneumothorax.
Blood pressure
Pain and anxiety may lead to hypertension.
Hypotension is a late sign of a tension pneumothorax.
Capillary re
Capillary re
Jugular venous pressure (JVP)
An elevated JVP may be apparent in tension pneumothorax due to increased intrathoracic pressure.
Fluid balance assessment
Calculate the patient’s
Calculate the patient's current
drain output, stool output, vomiting) to inform resuscitation e
Reduced urine output (oliguria) is typically de
Investigations and procedures
Intravenous cannulation
Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.
See our intravenous cannulation guide for more details.
Blood tests
Blood test results are unlikely to change the initial management of pneumothorax but may be useful in the diagnosis of
underlying causes (e.g. pneumonia).
Collect blood tests after cannulating the patient including\:
FBC\: to rule out anaemia and to look for a raised white cell count which may suggest underlying infection.
U&Es
LFTs
CRP\: to screen for evidence of in
Coagulation\: to screen for clotting abnormalities that might alter management (e.g. decision on inserting a chest drain).
Record an ECG
An ECG can be useful to help exclude cardiac causes of chest pain if these are suspected.
An ECG will likely be normal in the context of pneumothorax.
Performing an ECG should not delay your initial management of the pneumothorax.
Interventions
Intravenous
Hypovolaemic patients require
Administer a 500ml bolus Hartmann’s solution or 0.9% sodium chloride (warmed if available) over less than 15 mins.
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Administer 250ml boluses in patients at increased risk of
After each
Repeat administration of
reassessing the patient each time.
Seek senior input if the patient has a negative response (e.g. increased chest crackles) or if the patient isn't responding
adequately to repeated boluses (e.g. persistent hypotension).
See our for more details on resuscitation
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Disability
Clinical assessment
Consciousness
In the context of pneumothorax, a patient's consciousness level may be reduced secondary to hypoxia or cardiac tamponade
in tension pneumothorax.
Assess the patient's level of consciousness using the AVPU scale\:
Alert\: the patient is fully alert, although not necessarily orientated.
Verbal\: the patient makes some kind of response when you talk to them (e.g. words, grunt).
Pain\: the patient responds to a painful stimulus (e.g. supraorbital pressure).
Unresponsive\: the patient does not show evidence of any eye, voice or motor responses to pain.
If a more detailed assessment of the patient's level of consciousness is required, use the Glasgow Coma Scale (GCS).
Pupils
Assess the patient's pupils\:
Inspect the size and symmetry of the patient's pupils. Asymmetrical pupillary size may indicate intracerebral pathology.
Assess direct and consensual pupillary responses which may reveal evidence of intracranial pathology or lung cancer (e.g.
Horner's syndrome).
Drug chart review
anxiolytics).
Review the patient's drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives,
Investigations
Blood glucose and ketones
Measure the patient's capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g.
hypoglycaemia or hyperglycaemia).
A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).
The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.
Hypoglycaemia is de≤4.0
mmol/L should be treated if the patient is symptomatic.
If the blood glucose is elevated, check ketone levels which if also elevated may suggest a diagnosis of diabetic ketoacidosis
(DKA).
See our blood glucose measurement, hypoglycaemia and diabetic ketoacidosis guides for more details.
Imaging
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Request a CT head if intracranial pathology is suspected after discussion with a senior.
See our guide on interpreting a CT head for more details.
Interventions
Maintain the airway
Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants
urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient's airway as
explained in the airway section of this guide.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Exposure
It may be necessary to expose the patient during your assessment\: remember to prioritise patient dignity and conservation of
body heat.
Clinical assessment
Inspection
Inspect for evidence of chest trauma (e.g. penetrating chest trauma in tension pneumothorax) and injuries elsewhere.
Review the output of the patient's catheter and any surgical drains.
Bleeding
If active bleeding is identi
Estimate the total blood loss and the rate of blood loss.
Re-assess for signs of hypovolaemic shock (e.g. hypotension, tachycardia, pre-syncope, syncope).
Temperature
Assess the patient's temperature\: fever may indicate an infective cause underlying pneumothorax (e.g. pneumonia).
Investigations
Further imaging
Further imaging may be required in the context of trauma, such as CT thorax, however, this should not delay initial
management of pneumothorax.
Group and save
If the patient is bleeding or may require surgery send a group, save +/- crossmatch if not already performed.
Interventions
Trauma and bleeding
If the patient has su
(e.g. orthopaedic surgery, plastic surgery, vascular surgery).
If the patient has lost a signi
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Re-assess ABCDE
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Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the
e
Deterioration should be recognised quickly and acted upon immediately.
Seek senior help if the patient shows no signs of improvement or if you have any concerns.
Support
You should have another member of the clinical team aiding you in your ABCDE assessment, such as a nurse, who can perform
observations, take samples to the lab and catheterise if appropriate.
You may need further help or advice from a senior sta
about your patient.
Use an eSBARR handover to communicate the key information e
Next steps
Well done, you've now stabilised the patient and they're doing much better. There are just a few more things to do...
Take a history
Revisit history taking to identify risk factors for PE and explore relevant medical history. If the patient is confused you might be
able to get a collateral history from sta
See our history taking guides for more details.
Review
Review the patient's notes, charts and recent investigation results.
Review the patient's current medications and check any regular medications are prescribed appropriately.
Document
Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the
patient's response.
See our documentation guides for more details.
Discuss
Discuss the patient's current clinical condition with a senior clinician using an SBARR style handover.
Questions which may need to be considered include\:
Are any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Does the patient need reviewing by a specialist?
Should any changes be made to the current management of their underlying condition(s)?
Handover
The next team of doctors on shift should be made aware of any patient in their department who has recently deteriorated.
References
1. BTS Guidelines. Management of spontaneous pneumothorax\: British Thoracic Society pleural disease guideline 2010. Available
from\: [LINK].
Source\: geekymedics.com
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