Pneumothorax can become fatal before an X-ray is available. Air in the pleural space separates the lung from the chest wall. A small, stable pneumothorax may be observed, but a large, traumatic or tension pneumothorax can cause severe hypoxaemia, obstructive shock and cardiac arrest. EMTs must identify the clinical emergency, give oxygen, avoid delays for imaging in suspected tension pneumothorax, decompress only when trained and authorised, and arrange definitive chest drainage. Follow the current Uganda trauma/emergency protocol and senior clinician direction.
1. Learning objectives
- Define spontaneous, traumatic, iatrogenic, open and tension pneumothorax.
- Recognise the signs of a simple pneumothorax, tension physiology and associated haemothorax.
- Perform a safe trauma-focused ABCDE assessment and provide immediate pre-hospital care.
- Explain needle decompression, chest drainage, oxygen, analgesia and monitoring principles.
- Plan nursing care, referral, follow-up, recurrence prevention and patient education.
2. What is a pneumothorax?
A pneumothorax is air between the visceral and parietal pleura. The negative pressure that normally keeps the lung expanded is lost, so part or all of the lung collapses. A tension pneumothorax develops when air enters but cannot escape, progressively compressing the lung, mediastinum and great vessels. Falling venous return causes obstructive shock.
| Type | Cause/context | Emergency implication |
|---|---|---|
| Primary spontaneous | Rupture of a bleb in a person without known lung disease, often tall/thin or a smoker. | May be small and stable, but sudden deterioration is possible. |
| Secondary spontaneous | COPD, TB, asthma, cystic fibrosis, cancer or fibrotic disease. | Less physiological reserve; even a small pneumothorax may cause severe distress. |
| Traumatic | Blunt/penetrating chest injury, rib fracture, blast or crush injury. | May coexist with haemothorax, lung contusion, airway injury or cardiac trauma. |
| Iatrogenic | Central line, biopsy, ventilation, thoracentesis or other procedure. | Monitor after procedures; positive-pressure ventilation can rapidly worsen it. |
| Open pneumothorax | Chest-wall wound allows air to move through the wound. | Seal with a vented/three-sided dressing and watch for tension. |
| Tension pneumothorax | One-way air trapping with circulatory and respiratory compromise. | Clinical diagnosis; immediate decompression is required—do not wait for imaging. |
3. Causes and risk factors
- Smoking, previous pneumothorax, COPD, TB and other chronic lung disease.
- High-pressure ventilation, difficult vascular access, chest procedures and chest trauma.
- Sudden pressure changes, diving or air travel before complete resolution.
- Delayed recognition after trauma, especially when pain and distress are attributed to the injury alone.
4. Clinical features
| Finding | Simple pneumothorax | Tension pneumothorax |
|---|---|---|
| Symptoms | Sudden unilateral pleuritic pain, breathlessness, dry cough. | Severe distress, rapidly worsening dyspnoea, chest pain, fear or collapse. |
| Inspection | Reduced movement on affected side. | Marked distress, cyanosis, distended neck veins, possible tracheal shift late. |
| Palpation/percussion | Reduced expansion and tactile fremitus; hyperresonance may occur. | Very poor expansion, hyperresonance, weak/absent breath sounds. |
| Circulation | Usually preserved if small. | Tachycardia, hypotension, narrow pulse pressure, delayed refill, obstructive shock. |
| Neurologic | Anxiety from pain/dyspnoea. | Agitation, confusion, reduced consciousness or arrest from hypoxia/shock. |
Do not wait for tracheal deviation. It is a late and unreliable sign. In a crashing patient with unilateral absent breath sounds and shock, treat suspected tension pneumothorax clinically.
5. Focused history and examination
- Ask about sudden pain, breathlessness, trauma, procedure, ventilation, smoking, TB/COPD, prior episodes and timing.
- Inspect both sides of the chest for wounds, bruising, paradoxical movement, asymmetry and surgical emphysema.
- Palpate expansion, tracheal position, clavicles, ribs and subcutaneous crepitus; auscultate both lungs.
- Check pulse, BP, capillary refill, JVP, skin, SpO₂, respiratory rate and mental state.
- Look for haemothorax, flail chest, pulmonary contusion, tamponade and airway injury in trauma.
6. ABCDE and immediate treatment
| Step | Assessment | Action |
|---|---|---|
| A – Airway | Voice, obstruction, facial injury, blood/vomit, consciousness. | Open/protect airway, suction, airway adjunct if trained and prepare advanced support. |
| B – Breathing | Rate, effort, chest movement, wounds, breath sounds, SpO₂. | High-concentration oxygen for distress/hypoxaemia; seal open wound; decompress suspected tension when trained. |
| C – Circulation | Pulse, BP, refill, bleeding and shock. | Control bleeding, IV/IO access, cautious fluids and urgent transfer for chest drainage. |
| D – Disability | AVPU/GCS, agitation, hypoxia and glucose. | Check glucose, protect airway and treat arrest immediately if present. |
| E – Exposure | Complete trauma survey, posterior chest, wounds and temperature. | Prevent heat loss, preserve dignity, log-roll carefully and reassess after every intervention. |
7. Tension pneumothorax: the life-threatening pathway
- Suspect it with severe respiratory distress plus unilateral absent breath sounds, shock or traumatic chest findings.
- Call for resuscitation/trauma help, give oxygen and prepare immediate decompression; do not delay for chest X-ray or ultrasound in an unstable patient.
- Needle decompression is a temporary rescue procedure. It must be performed by trained, authorised personnel using the local site, catheter and safety protocol.
- Definitive treatment is an appropriately placed chest tube or equivalent drainage by an experienced clinician.
- Reassess breath sounds, chest movement, pulse, BP and SpO₂ after decompression; recurrence or failure requires urgent expert review.
8. Open pneumothorax and chest wounds
- Apply a sterile occlusive dressing that allows air to escape, commonly a three-sided or vented dressing according to local trauma protocol.
- Do not fully seal a sucking chest wound without monitoring; converting it to a closed one-way trap can create tension.
- Look for another wound on the chest/back, control external bleeding and provide oxygen.
- Monitor for increasing distress, hypotension and reduced breath sounds—tension can develop after sealing.
- Arrange urgent surgical/chest-drain care and give analgesia under protocol.
9. Investigations
- Chest X-ray confirms many stable pneumothoraces and may show lung edge, mediastinal shift or associated fluid.
- Point-of-care ultrasound can support a rapid diagnosis when trained personnel are available, but a negative or uncertain scan must not delay treatment of a crashing patient.
- CT is useful for complex trauma, small occult pneumothorax or surgical planning in a stable patient.
- ECG, blood gas, FBC, group-and-save/crossmatch and renal tests are guided by severity and trauma context.
- Repeat imaging after aspiration, chest-drain placement or clinical deterioration according to local protocol.
10. Definitive management principles
| Situation | Possible approach | Important caution |
|---|---|---|
| Small, stable, minimal symptoms | Observation, analgesia, oxygen if hypoxaemic and planned repeat imaging. | Requires reliable follow-up and clear return precautions. |
| Large or symptomatic | Needle aspiration or chest drain, depending on protocol, cause and expertise. | Monitor for re-expansion problems and persistent air leak. |
| Traumatic/open | Wound dressing, chest tube, trauma resuscitation and surgical review. | Search for haemothorax and other injuries. |
| Tension/unstable | Immediate decompression followed by definitive chest drainage. | Do not wait for imaging; repeat ABCDE continuously. |
| Recurrent/persistent leak | Respiratory/thoracic surgical review; pleurodesis or surgery may be considered. | Smoking cessation and follow-up are essential. |
11. Nursing and EMT care plan
| Problem | Interventions | Evaluate |
|---|---|---|
| Impaired gas exchange | Upright positioning, oxygen, SpO₂/ECG monitoring and airway readiness. | Breathing effort, SpO₂, speech, breath sounds and mental state. |
| Chest pain | Prescribed analgesia, support coughing, avoid unnecessary exertion and monitor sedation. | Pain score, respiratory effort and ability to cooperate. |
| Shock risk | Frequent vitals, IV access, fluid balance, warmth and urgent escalation. | Pulse, BP, refill, urine and skin perfusion. |
| Chest drain | Keep system upright/below chest, check tubing, dressing, bubbling/swinging and insertion site. | Drain patency, air leak, lung re-expansion and infection signs. |
| Anxiety/education | Explain procedures, stay with patient, provide return precautions and smoking/flying advice. | Understanding, safe mobility and follow-up attendance. |
12. Chest-drain safety
- Secure all connections, keep the drainage unit below chest level and avoid dependent loops or kinking.
- Do not clamp a bubbling drain unless specifically directed by an experienced clinician; clamping an active air leak may precipitate tension.
- Record bubbling, swinging, output, dressing condition, pain, subcutaneous emphysema and respiratory observations.
- If the tube disconnects, follow local protocol: maintain sterility, reconnect or place the end in sterile fluid only if trained and instructed.
- If the tube falls out, cover the site with an appropriate sterile dressing and call for urgent help.
13. Special populations and complications
- Children/neonates: small changes can cause rapid compromise; urgent paediatric/anaesthetic support is required.
- COPD/TB: secondary pneumothorax may be severe despite a modest radiographic size.
- Positive-pressure ventilation: can rapidly convert a simple pneumothorax to tension; reassess after intubation or deterioration.
- Pregnancy: maintain maternal oxygenation and involve obstetric/respiratory teams.
- Complications: tension recurrence, haemothorax, persistent air leak, re-expansion pulmonary oedema, infection, nerve/vessel injury and recurrence.
14. Discharge, follow-up and prevention
- Stable patients need a documented repeat-imaging and respiratory follow-up plan.
- Return immediately for increasing breathlessness, sudden pleuritic pain, fainting, cyanosis or new confusion.
- Do not fly until the pneumothorax has fully resolved and a clinician confirms safe travel; avoid scuba diving unless a specialist has cleared it.
- Stop smoking and address COPD, TB or other underlying lung disease.
- Teach wound/chest-drain care, medication use, activity restrictions and who to contact after discharge.
15. Clinical scenarios
Scenario 1 – tension after trauma. A motorcyclist has severe dyspnoea, hypotension, unilateral absent breath sounds and worsening cyanosis. Give oxygen, call trauma help and perform authorised emergency decompression without waiting for X-ray, followed by definitive chest drainage.
Scenario 2 – open chest wound. A patient has a sucking wound after a stab injury. Apply a vented/three-sided dressing, oxygen, monitor closely for tension, control bleeding and arrange urgent chest-tube/surgical care.
Scenario 3 – secondary spontaneous pneumothorax. A person with COPD develops sudden chest pain and dyspnoea. Treat hypoxaemia, avoid excessive oxygen without a target, assess severity and refer urgently because a small pneumothorax may cause major compromise.
Scenario 4 – deterioration after intubation. Immediately after ventilation, BP falls and one side has absent breath sounds. Suspect tension pneumothorax, check tube position and decompress urgently while continuing resuscitation.
16. Common errors to avoid
- Waiting for tracheal deviation or X-ray in an unstable patient.
- Performing needle decompression without training, equipment or a definitive drainage plan.
- Sealing an open wound completely without a vent or monitoring for tension.
- Clamping a bubbling chest drain or lifting the drainage unit above the chest.
- Ignoring haemothorax, tamponade, flail chest, pulmonary contusion or airway injury.
- Discharging without imaging follow-up, flying advice, smoking cessation and return precautions.
PNEUMOTHORAX emergency check – “CHEST”
C – Check ABCDE and chest asymmetry
H – Hypoxaemia and shock mean urgent action
E – Expose wounds and examine both sides
S – Seal open wounds and support breathing
T – Tension needs immediate trained decompression and chest tube
C – Check ABCDE and chest asymmetry
H – Hypoxaemia and shock mean urgent action
E – Expose wounds and examine both sides
S – Seal open wounds and support breathing
T – Tension needs immediate trained decompression and chest tube
17. Revision questions
- Define simple, traumatic, open and tension pneumothorax.
- Explain how tension pneumothorax causes obstructive shock.
- List the key clinical features that justify immediate decompression.
- Describe pre-hospital care for an open chest wound.
- What chest-drain observations must be documented?
- List five complications and six discharge instructions.
18. Key take-home points
- Tension pneumothorax is a clinical diagnosis in an unstable patient; do not delay decompression for imaging.
- Give oxygen, monitor continuously and arrange definitive chest drainage.
- Open chest wounds need a vented/three-sided dressing and urgent surgical care.
- Secondary pneumothorax can be dangerous even when the radiographic size seems small.
- Chest-drain safety, follow-up imaging and recurrence prevention are part of emergency care.
Safety note: This is educational content for EMT students. Needle decompression, chest-tube insertion and ventilatory management are invasive procedures requiring approved training, equipment, local protocol and senior supervision.
References for further study
- WHO Basic Emergency Care: ABCDE and tension pneumothorax
- WHO IMAI District Clinician Manual
- NHS: Pneumothorax assessment and treatment
- Uganda Ministry of Health: current trauma, chest-drain and emergency-care protocols.