What causes tension pneumothorax?

Updated: Apr 28, 2020
  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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The most common etiologies of tension pneumothorax are either iatrogenic or related to trauma, such as the following:

  • Blunt or penetrating trauma - Disruption of either the visceral or parietal pleura occurs and is often associated with rib fractures, though rib fractures are not necessary for tension pneumothorax to occur.
  • Barotrauma secondary to positive-pressure ventilation (PPV), especially when high amounts of positive end-expiratory pressure (PEEP) are used
  • Pneumoperitoneum [18, 19]
  • Fiberoptic bronchoscopy with closed lung biopsy [20]
  • Markedly displaced thoracic spine fractures
  • Acupuncture [21, 22, 23]
  • Preexisting Bochdalek hernia with trauma [24]
  • Colonoscopy [25] and gastroscopy have been implicated in case reports.
  • Percutaneous tracheostomy [26]
  • Conversion of idiopathic, spontaneous, simple pneumothorax to tension pneumothorax
  • Unsuccessful attempts to convert an open pneumothorax to a simple pneumothorax in which the occlusive dressing functions as a one-way valve

Tension pneumothorax occurs commonly in the ICU setting in patients who are ventilated with positive pressure, and practitioners must always consider this when changes in respiratory or hemodynamic status occur. Infants requiring ventilatory assistance and those with meconium aspiration have a particularly high risk for tension pneumothorax. Aspirated meconium may serve as a one-way valve and produce a tension pneumothorax.

Any penetrating wound that produces an abnormal passageway for gas exchange into the pleural spaces and that results in air trapping may produce a tension pneumothorax. Blunt trauma, with or without associated rib fractures, and incidents such as unrestrained head-on motor vehicle accidents, falls, and altercations involving laterally directed blows may also cause tension pneumothoraces.

Significant chest injuries carry an estimated 10-50% risk of associated pneumothorax; in about 50% of these cases, the pneumothorax may not be seen on standard radiographs and are therefore deemed occult. In one study, 12% of patients with asymptomatic chest stab wounds had a delayed pneumothorax or hemothorax. McPherson et al analyzed data from the Vietnam Wound Data and Munitions Effectiveness Team study and determined that tension pneumothorax was the cause of death in 3-4% of fatally wounded combat casualties. [27]

Acupuncture is a traditional Chinese medicine technique used worldwide by alternative medical practitioners. Acupuncture's most frequently reported serious complication is pneumothorax; in one Japanese report of 55,291 acupuncture treatments, an approximate incidence of 1 pneumothorax in 5000 cases was documented. [28]

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