In the Field
Pneumothorax is the parent term for several specific conditions, including the tension pneumothorax that kills patients quickly and the open pneumothorax (sucking chest wound) that brought the chest seal into your kit. Understanding the basic concept matters because the field interventions are different for different forms. A simple pneumothorax often needs no field intervention beyond monitoring. A tension pneumothorax requires needle decompression. An open pneumothorax requires a chest seal. Recognizing which one you are looking at drives the response.
Common Mistake
Treating every pneumothorax the same way, when the appropriate intervention depends on whether the pneumothorax is simple, open, or under tension.
Technical Detail
A pneumothorax is the abnormal presence of air in the pleural space, the potential space between the visceral pleura covering the lung and the parietal pleura lining the chest wall. Normally this space contains a small amount of fluid and maintains negative pressure that holds the lung expanded against the chest wall. When air enters the space, the negative pressure is lost and the lung partially or fully collapses on the affected side.
Categories. Pneumothorax is divided into several types based on cause and physiology:
Simple (closed) pneumothorax. Air in the pleural space without an open chest wall wound. Caused by blunt trauma with rib fracture, spontaneous lung rupture, or barotrauma. The lung partially collapses but pressure does not progressively rise. Often does not require immediate field intervention beyond monitoring and oxygen if available.
Open pneumothorax. Air enters the pleural space through an open chest wall wound, typically from a penetrating injury. Often called a sucking chest wound when the wound is visible and audible. Treated with a chest seal. See the Open Pneumothorax entry for detail.
Tension pneumothorax. Air enters the pleural space and cannot escape, creating a one-way valve effect that progressively builds pressure. Compresses the lungs and heart. Rapidly fatal without intervention. Treated with needle decompression. See the Tension Pneumothorax entry for detail.
Hemopneumothorax. The presence of both air and blood in the pleural space. Common in penetrating chest trauma where both the lung and surrounding vessels are injured.
Field signs. Common to most pneumothoraces:
Penetrating chest wound or significant blunt chest trauma (mechanism).
Decreased or absent breath sounds on the affected side.
Respiratory distress, ranging from mild in simple pneumothorax to severe in tension pneumothorax.
Chest pain on the affected side.
Hyperresonance to percussion on the affected side.
Field treatment by type. The treatment depends on the specific form. Simple pneumothorax may require only monitoring. Open pneumothorax requires a chest seal. Tension pneumothorax requires needle decompression. A patient who deteriorates after chest seal placement may have developed tension pneumothorax and may require burping the seal or escalating to decompression.
