Tension Pneumothorax – CXR

Table of Contents

Table of Contents

Cullen Buchanan, MD
Expert review – pending

Objectives

1. Identify key features on a chest X-ray that differentiate a tension pneumothorax from a simple pneumothorax.

Teaching Instructions

Plan to spend 5-10 minutes familiarizing yourself with the animations of the PowerPoint and the key findings of this chest X-ray.

Present the image either by expanding the window (bottom right) in a browser or downloading the PowerPoint file (downloading is recommended).  Have the image pulled up in presenter mode before learners look at the screen to avoid revealing the diagnosis.  Ask a learner to provide an overall interpretation.  Then advance through the animations to prompt learners with key questions and reveal the findings, diagnosis, and teaching points.

Instructions: Ask a learner to provide an overall interpretation.  Advance the slide for subsequent questions.

CXR Read: large right pneumothorax, multiple displaced right anterior rib fractures, right axillary chest wall emphysema. An endotracheal tube terminates approximately 6cm above the carina. The esophagogastric tube terminates below the field of view. Left apical-predominant hazy opacities. No pleural effusion.

Diagnosis: Tension pneumothorax following multiple rounds of CPR for ventricular fibrillation arrest. Hypoxemia and shock resulting from lung collapse and reduced venous return.

Teaching: The primary aim of this image is to identify the key features that distinguish a tension pneumothorax from a simple pneumothorax. The three key findings in this image are:
1. Contralateral mediastinal shift
2. Ipsilateral spreading of ribs
3. Ipsilateral flattening and depression of the diaphragm

There is also obvious evidence for the mechanism with multiple displaced fractures and chest wall emphysema.

Presentation Board

Take Home Point

Tension pneumothorax often presents as a hyperacute respiratory and hemodynamic collapse. It is readily identified by the unilateral absence of breath sounds and radiographic evidence of increased intra-thoracic pressure:

  1. Contralateral mediastinal shift
  2. Ipsilateral spreading of ribs
  3. Ipsilateral flattening and depression of the diaphragm

References

McLoud, Boiselle, & Boiselle, Phillip M. (2010). Thoracic radiology : The requisites (2nd ed., Requisites in radiology). Philadelphia: Mosby/Elsevier.

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