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Spontaneous tension pneumothorax: what is it and does it exist?
G Simpson1, S Vincent, J Ferns
1Department of Thoracic Medicine, Cairns Base Hospital, Cairns, Queensland, Australia. fgsimpson@iig.com.au
Internal Medicine Journal
|December 11, 2012
Summary
Tension pneumothorax, a condition where intrapleural pressure exceeds atmospheric pressure, may not be caused by high pressures in spontaneously breathing patients. The term and its underlying mechanisms require reconsideration in clinical practice.
Area of Science:
- Pulmonology
- Critical Care Medicine
- Thoracic Surgery
Background:
- Tension pneumothorax is characterized by intrapleural gas pressure exceeding atmospheric pressure.
- This condition is associated with mediastinal shift and cardiovascular collapse.
- A valvular defect allowing unidirectional air entry is the proposed mechanism.
Purpose of the Study:
- To critically evaluate the definition and mechanism of tension pneumothorax.
- To question the role of high intrapleural pressures in spontaneously breathing patients.
- To suggest reconsideration of the term 'tension pneumothorax' in this patient population.
Main Methods:
- Review of existing definitions and proposed mechanisms of tension pneumothorax.
- Analysis of physiological principles governing pleural pressure dynamics.
- Examination of evidence from pilot experiments and case reports in spontaneously breathing patients.
Main Results:
- Intrapleural pressure cannot exceed atmospheric pressure during inspiration in spontaneously breathing individuals.
- All pneumothoraces exhibit pressures greater than atmospheric during expiration, essential for drainage.
- Pilot studies and rare case reports suggest alternative explanations for clinical deterioration, questioning high-pressure mediation.
Conclusions:
- The traditional understanding of tension pneumothorax, particularly regarding high intrapleural pressures, may be inaccurate for spontaneously breathing patients.
- Urgent intervention for large pneumothoraces is necessary, but the mechanism is unlikely solely due to elevated pressures.
- The clinical term 'tension pneumothorax' in spontaneously breathing patients warrants re-evaluation.
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