Pneumothorax
Key Points
- Pneumothorax is the accumulation of air in the pleural space (normally contains only 10–20 mL of fluid), causing partial or complete lung collapse.
- Three major types: primary spontaneous (no underlying disease, young males 20–30), secondary spontaneous (complication of COPD, asthma, pneumonia), and traumatic (penetrating chest injury, iatrogenic from procedures).
- Classic assessment: sudden-onset dyspnea, pleuritic chest pain, decreased or absent breath sounds on the affected side, and unequal chest expansion.
- Tension pneumothorax is a life-threatening emergency — tracheal deviation, hypotension, and cyanosis require immediate needle decompression (no time for imaging).
- Management ranges from observation (small, asymptomatic) to high-flow oxygen, needle aspiration, or chest tube insertion.
Pathophysiology
The pleural space lies between the visceral pleura (covering the lung) and the parietal pleura (lining the chest wall). Air enters this space through:
- A breach in the chest wall (traumatic: penetrating injury, iatrogenic procedure)
- Rupture of the visceral pleura (spontaneous: ruptured bleb or bulla)
Accumulated air increases intrapleural pressure, causing the lung to collapse and deflate. As gas exchange area decreases, oxygenation and ventilation are severely impaired.
Tension pneumothorax: A one-way valve mechanism allows air to enter the pleural space with each breath but prevents its exit. Progressive air accumulation shifts the trachea, heart, and mediastinal structures away from the affected side, compressing the contralateral lung and reducing venous return through the vena cava/right heart. Cardiac output and blood pressure can drop rapidly, causing cardiovascular collapse.
Types of Pneumothorax
| Type | Cause | Population |
|---|---|---|
| Primary spontaneous | Ruptured subpleural bleb; no underlying lung disease | Young males age 20–30; tall, thin body habitus |
| Secondary spontaneous | Complication of underlying lung disease (COPD, asthma, cystic fibrosis, TB) | Older adults age 60–65; history of pulmonary disease |
| Traumatic | Penetrating or blunt chest injury | Any age; trauma patients |
| Iatrogenic | Complication of procedures (central line placement, thoracentesis, lung biopsy) | Hospitalized patients |
Risk factors: Smoking (heavy smokers have 102× higher risk vs nonsmokers), COPD, family history, pregnancy.
Nursing Assessment
NCLEX Focus
Tension pneumothorax is a medical emergency requiring immediate needle decompression — do NOT wait for chest X-ray. Classic triad: absent breath sounds on affected side + tracheal deviation AWAY from affected side + hypotension. Act immediately.
Clinical manifestations:
- Sudden-onset dyspnea, pleuritic chest pain worsening with movement, and cough
- Increased respiratory rate, decreased SpO₂, tachycardia
- Decreased or absent breath sounds on the affected side
- Unequal chest expansion (affected side lags or does not rise)
- Subcutaneous emphysema — “popping” sensation (crepitus) on palpation of chest/neck
Tension pneumothorax (emergency — act immediately):
- Severe hypotension, cyanosis, diaphoresis
- Tracheal deviation away from the affected side
- Jugular venous distension (JVD)
- Markedly decreased or absent breath sounds unilaterally
- Rapid deterioration and cardiovascular collapse
Diagnostics:
- Chest X-ray: visualizes area of collapsed lung (air-density gap between lung margin and chest wall)
- CT scan (more sensitive, especially for small pneumothorax)
- Point-of-care lung ultrasound
- Pulse oximetry and ABG (SpO₂ decreased, PO₂ decreased, respiratory alkalosis initially)
- Tension pneumothorax: treat immediately — do not delay for imaging
Nursing Interventions
Initial priorities:
- Place patient in semi-Fowler’s or upright position — optimizes respiratory mechanics
- Administer supplemental oxygen as ordered (high-flow O₂ speeds reabsorption of pleural air)
- Monitor SpO₂ continuously; notify provider of any deterioration
Management by severity:
| Severity | Treatment |
|---|---|
| Small, asymptomatic | Watchful waiting; supplemental O₂ to speed air reabsorption; serial imaging |
| Symptomatic, moderate | Needle aspiration between ribs into pleural space to decompress |
| Large or secondary | Chest tube (thoracostomy tube) insertion; connect to closed drainage system |
| Tension pneumothorax | Immediate needle decompression (2nd intercostal space, midclavicular line) → chest tube |
Chest tube care (when present):
- Ensure chest tube is securely connected to closed drainage system at all times
- Keep drainage system below chest level; do not clamp without provider order
- Monitor output (color, volume, air leak — oscillation with respirations = patent tube)
- Assess insertion site dressing for drainage, crepitus, or signs of infection
- If chest tube becomes dislodged: apply three-sided occlusive dressing — allows air to escape, prevents air entry on 3 sides
- If tension pneumothorax signs appear: anticipate emergent needle decompression
Tension Pneumothorax — Emergency Response
Sudden deterioration with absent unilateral breath sounds + tracheal deviation + hypotension = tension pneumothorax. Call rapid response immediately. Anticipate emergent needle thoracostomy (needle decompression at 2nd ICS, MCL) followed by chest tube placement. Do not leave the patient unattended.
Pain management:
- Advocate for and administer analgesia before and after needle aspiration or chest tube insertion — both procedures cause moderate to severe pain
- Reassess pain after intervention
Evaluation of outcomes:
- Improved SpO₂ and decreased respiratory distress
- Return of bilateral breath sounds
- Decreased air output in chest drainage system as pneumothorax resolves
- Repeat imaging confirms lung re-expansion
Related Concepts
- respiratory-system — Normal pleural space anatomy and pressure dynamics disrupted in pneumothorax.
- chest-tube-drainage-system-safety-monitoring — Chest tube care, drainage system management, and dislodgement response.
- evidence-based-respiratory-care — Oxygen therapy to accelerate air reabsorption in pneumothorax.
- respiratory-failure — Severe pneumothorax as a cause of acute respiratory failure requiring emergent intervention.
- thorax-and-lung-assessment-breath-sounds-and-respiratory-patterns — Auscultation findings and percussion in pneumothorax assessment.
- pain-management — Pain management for chest tube procedures and pneumothorax.
Self-Check
- A client develops sudden severe dyspnea, absent breath sounds on the left side, and the trachea is shifted to the right. What emergency intervention should the nurse anticipate and what is the rationale?
- A client has a chest tube in place. The nurse notices the chest tube has become dislodged. What is the immediate priority nursing action?
- What clinical findings distinguish a simple pneumothorax from a tension pneumothorax, and why does this distinction matter for treatment?