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PNEUMOTHORAX

Contributed by: Brad Wilson, NRP

OVERVIEW

During respirations, the diaphragm contracts and causes a negative pressure in the plural cavity, causing the lungs to expand and fill with air. When the diaphragm relaxes, a positive pressure is created and allows the lungs to deflate.  During certain traumatic injuries, the lungs can be damaged with punctures, causing the lung to “deflate” and not react to the pressure gradients in the plural cavity. This condition is called a pneumothorax.

A pneumothorax can be either open or closed and is reported to present in roughly 15% – 50% of all reported chest injuries.1 An open pneumothorax, commonly called a sucking chest wound, occurs when the plural cavity is penetrated from outside the body. This release of pressure will cause the lung from the affected side to collapse. Pneumothorax (PTX) can be divided into three different types, spontaneous, traumatic, or tension. In the realm of athletics, a traumatic or spontaneous PTX is most likely to occur. Traumatic PTX can be further subdivided into penetrating or non-penetrating trauma. While rare, traumatic PTX have been reported in sports such as ice hockey, football, rugby, and soccer. For the most part, sports-related PTX are due to blunt chest trauma. Luckily, in athletics, PTX is rare.  Only about 2% of adult pneumothorax injuries are due to athletics.2

Spontaneous Pneumothorax
A spontaneous pneumothorax occurs when air escapes from the lung causing it to collapse. This type of pneumothorax occurs for no apparent reason.

Traumatic Pneumothorax
A traumatic pneumothorax results from a puncture wound to the lung, causing the lung to collapse. This can be life-threatening.

Tension pneumothorax
A tension pneumothorax is a severe pneumothorax that can be life-threatening. The cause of this type of pneumothorax can be a traumatic event, or a severe spontaneous pneumothorax. The lung collapse is usually more than 50%.

Individuals who are young, thin, and tall, such as basketball players, are most susceptible to the development of a primary spontaneous pneumothorax. Individuals in high blunt chest trauma risk sports are also at increased risk when compared to non-contact sports.  At times the plural cavity may fill with blood, do to barotrauma, causing a hemothorax. In very rare instances, an athlete might experience an open penetrating chest wound, causing an open pneumothorax.

One final type of injury that could be caused by trauma to the chest cavity is a hematoma. A hematoma acts just like a pneumothorax, except blood fills the cavity instead of air. Each of the body’s thoracic cavities can accumulate up to 3000ml of blood. A “massive” hemothorax occurs when at least 1500ml of blood accumulates in the plural cavity.

Risk Factors

Risk factors include:

Recognition and Management

Signs and Symptoms

Late signs of a worsened PTX

Acute Care and Management of a pneumothorax

  1. Maintain an open airway.
  2. Give oxygen via a non-rebreather facemask. At 15 l/min
  3. Check lung sounds using a stethoscope.
    1. Make sure to check for breath sounds in all lobes of the lungs (see diagram)
    2. Listen to the lungs both anteriorly and posteriorly.
  4. Check the respiratory rate, rhythm and depth.
  5. Look for equal and bilateral chest expansion during respirations.
  6. Check pulse.
  7. Activate EMS for immediate transport to appropriate receiving facility if the athlete has these signs and symptoms:
    1. Penetrating chest trauma;
    2. Jugular vein distension;
    3. Shallow breathing;
    4. Tachycardia;
    5. Tachypnea;
    6. Decreased breath sounds.

Once EMS arrives, they will determine if there is a pneumothorax present. In the late stages, tracheal deviation will start to happen. The trachea will start to deviate in the direction of the unaffected lung. This occurs because of the pressure from the tension pneumothorax that has developed. This is dangerous to the compression being applied to the other organs. If a tension pneumothorax has developed, EMS well perform a needle decompression, “dart” the chest. This is performed by the provider using a 14g catheter in the second intercostal space mid clavicular. Once the needle is removed from the catheter, air or blood (if a hemothorax) will be observed.  This release of pressure will allow the lung to start to re-inflate.

When the patient arrives to the emergency department, a chest tube may be inserted, depending on how severe the pneumothorax or hemothorax is.

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