Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Pneumothorax and Tension Pneumothorax

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In one line

·A pneumothorax is air inside the chest that does not belong there, and it squeezes the lung so the lung cannot fill with air the way it should.

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Normal physiology

·Each lung is wrapped in a thin, double-layered skin called the pleura. The inner layer sticks to the lung; the outer layer lines the inside of the chest wall. Between them is the pleural space—a hair-thin gap that holds almost no air, only a tiny film of slippery fluid so the layers can slide smoothly when you breathe.

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What goes wrong

·Air gets into the pleural space where it does not belong. Once air is in that space, the negative-pressure vacuum is lost and the lung starts to collapse inward.

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Hallmark signs

·Sudden sharp chest pain on one side
·Shortness of breath
·Fast breathing
·Decreased or absent breath sounds on one side (heard with a stethoscope)
·Fast heart rate
·One side of the chest does not move as much when breathing
·Bulging neck veins and very low blood pressure (tension pneumothorax)
·Trachea (windpipe) shifted to one side (tension pneumothorax)

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Red flags · escalate now

·Very low blood pressure or shock (systolic below 90 mmHg)
·Bulging neck veins with respiratory distress
·Trachea visibly or palpably shifted away from the affected side
·Severe trouble breathing or unable to speak in full sentences
·Confusion, dizziness, or fainting

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Workup

·Upright chest X-ray (posteroanterior and lateral views)
·Arterial blood gas (ABG) on room air
·Bedside ultrasound of the chest (lung point sign, absence of lung sliding)
·Chest CT scan (if diagnosis is unclear or recurrent pneumothorax)
·Pulse oximetry (continuous oxygen saturation monitoring)
·Complete blood count (CBC)

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Treatment

·Immediate needle decompression (14- or 16-gauge needle at the 2nd intercostal space, midclavicular line) for tension pneumothorax
·Chest tube (tube thoracostomy) or small-bore pigtail catheter for large pneumothorax (>2 cm) or any symptomatic pneumothorax
·Observation and supplemental oxygen (or room air) for small (<2 cm), stable, primary spontaneous pneumothorax
·Video-assisted thoracoscopic surgery (VATS) with pleurodesis (scarring the pleura) or bleb resection (cutting out the weak air sac)
·Smoking cessation and activity restriction (no flying, no scuba diving, no heavy lifting) until healed
·Pain control with NSAIDs (ibuprofen, ketorolac) or acetaminophen; avoid opioids if possible

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NCLEX trap

·Tension pneumothorax can stop the heart within minutes. Do NOT wait for imaging. Decompress immediately with a needle into the chest (needle thoracostomy), then get the chest tube and X-ray afterward. Life first, picture second.
·Size and symptoms decide treatment. Small pneumothorax (under 2 cm rim on X-ray) in a stable patient: observe with supplemental oxygen and repeat imaging. Large pneumothorax (≥2 cm) or any symptomatic patient: chest tube or small-bore pigtail catheter. Tension pneumothorax: needle decompression first, then chest tube. One size does NOT fit all.
·Low blood pressure (hypotension) with pneumothorax is a red-flag sign of tension pneumothorax. The rising air pressure is squeezing the vena cava (the big vein that brings blood back to the heart) and the heart itself, so less blood fills the heart and blood pressure crashes. This is a life-threatening emergency—act NOW.
·Even a small pneumothorax can enlarge or turn into tension pneumothorax, especially in the first 24 hours. Admit or observe the patient closely. Recheck breath sounds, oxygen saturation, and vital signs frequently. If symptoms worsen or oxygen drops, escalate treatment immediately. Never assume 'small' means 'safe to ignore.'
·The traditional landmark is the 2nd intercostal space at the midclavicular line (just below the collarbone in the front). The 5th intercostal space midaxillary line (side of the chest) is an alternative that works well, especially in obese patients or those lying flat. Know BOTH spots and choose based on patient position, body habitus, and access. Either site releases trapped air quickly.
·Pain can fade because the patient calms down, takes pain medicine, or the pleura (lung lining) stops being stretched as violently—but the air is still there and the lung is still collapsed. Monitor breath sounds, oxygen saturation, and vital signs closely. Do NOT let pain relief trick you into missing a worsening or enlarging pneumothorax.

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