In the photo above, it's probably OK to make the assumption that even un-trained eyes know something is wrong with this patient. Maybe the stars and arrows overlaying the radiograph give it away. This chest x-ray is indeed abnormal and from a symmetry perspective alone, even those with no formal medical training could recognize a problem may exist. This image is a textbook case of tension pneumothorax. While this is an extreme example of a left lung pneumothorax where nearly the entire lung has collapsed, and the mediastinum and trachea have shifted to the right... - Keep in mind we have the ability to make this same diagnosis clinically in the field without the need for x-ray studies. In obvious cases like this, confirmation with radiology is not routinely recommended. What is recommended is quick field provider identification and subsequent needle decompression immediately. If possible, consider the 4th/5th intercostal space (ICS) along the anterior axillary line for needle placement as the research suggest the chest wall is its thinnest here. Additionally, the failure rate is significantly lower at this site when compared to the mid-axillary or mid-clavicular sites. From a hemodynamic perspective be on the lookout for the following signs/symptoms:
Hypotension/Tachycardia/JVD/Subcutaneous Air/Diminished or Absent Breath Sounds/Tracheal Deviation/Chest Wall Crepitus/Poor SpO2 Pleth/Point Chest Tenderness
Remember your lungs are not directly attached to your chest wall and active inspiration is only possible because of negative pressure (vacuum) creation within your chest cavity. The diaphragm helps immensely with this part of ventilation. Most treatments are aimed at restoring this negative pressure, because physics states that pressure and volume are inversely. proportional.
Clinically, these patients may have obvious chest trauma from a fall or an MVC. However, it's important to keep in mind that medical causes of pneumothorax and hemothorax are possible. Imagine a lung cancer patient who has a surgical intervention to resect some malignant lung tissue. She is discharged home 24 hours later and complains of dyspnea. During your primary impression you notice her neck is extremely swollen and her voice is strained. She hasn't fallen or been involved in an MVC. She has a massive hemothorax that has extending into her neck and surrounding soft tissues. This was a post-surgical (iatrogenic) complication. Fortunately, her trachea was still midline, and lung sounds (while diminished) were present bilaterally. The point I want to reinforce is that tension pneumothorax is a life-threatening event that needs treated right away, but lung collapse pathologies [obstructive or non-obstructive] take on many forms. Sometimes excess air in the pleural space is not causing the issue at all- that's what we'll review next...
The trouble can be systemic in some cases like ARDS, specific to one lobe of one lung or on an even smaller scale - localized to just a few alveoli.
Spontaneous (simple/non-traumatic) pneumothorax- no underlying lung disease
Lifting weights or even menstruation (catamenial) can cause recurrent pneumothorax
AND / OR
Lung mass (malignant cancer or something else)
Pleural effusions
Foreign objects
Lobar pneumonia
Generalized pulmonary edema (alveolar collapse - atelectasis)
Cystic fibrosis
Tuberculosis
Marfan Syndrome
Vaping
Incidents around deep-sea diving
Bottom line: expand your differentials around lung collapse and its causes:
It's not always a tension, it's not always caused by trauma, it's not always too much air.
March 27, 2023
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC.