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Tension pneumonia is a haemodynamic and/or respiratory disorder.

The clinical picture represents an acutely life-threatening situation which, without treatment, usually ends fatally. S.a. pneumothorax.

The tension pneumothorax is a rare clinical picture, which accounts for only about 3% of pneumothoraces.

It occurs most frequently during resuscitation or mechanical ventilation, but can also develop from a secondary or traumatic pneumothorax. It is always potentially life-threatening.

With a tension pneumo, air enters the pleural space with every breath due to a valve mechanism. This air can then no longer escape during expiration. This leads to an increase in pressure in the pleural space, which in turn displaces the mediastinum to the healthy side. This results in compression of the healthy side of the lung and impedes venous return. As a result, the CVD increases and the CVS decreases.

Within minutes to an hour, severe, increasing shortness of breath occurs and upper influence congestion occurs in combination with arterial hypotension.

Overall, the picture of a tension pneumothorax is somewhat different. The highest sensitivity has the

• Skin emphysema (sensitivity up to 100 %)

In addition, the typical and most frequent signs of a tension pneumonia in an awake patient are shortness of breath and tachycardia.

In the ventilated patient, the first important early symptom is a strongly increased or constantly rising airway pressure.

The following symptoms may also be present in patients:

• Cyanosis
• Tachypnea
• Drop in oxygen saturation
• suspended breathing excursions
• bulging hemithorax
• sharp chest pain, depending on breathing
• Stasis of the jugular veins
• Unconsciousness
• arterial hypotension (occurs relatively late in the course), can go as far as pulseless electrical activity
• Increase in the ZVD
• Waste of the HZV

Diagnosis

The S3 guideline gives the following key recommendations for diagnostics:

The suspected diagnosis of tension pneumothorax should be made at:

• unilateral absence of breath sound during auscultation of the lung (if necessary after checking the correct position of the tube)
• the additional presence of typical symptoms, in particular a severe respiratory disorder (paralysis of the respiratory centre as a result of hypoxia occurs before hypotension with circulatory arrest)
• or upper influence congestion in combination with arterial hypotension.

So far, there are no usable scientific data on the accuracy of the diagnosis "tension pneumothorax".

Auscultation

• hemiplegia

Knocking sound

• hypersonic knocking

The following diagnostics are only for the sake of completeness. As a rule, it will not be performed as an emergency because of the urgently required therapeutic measures.

X-ray

• Mediastinal displacement to the contralateral side
• Diaphragm depression

BGA

• severe respiratory disorder with marked hypoxemia and/or hypercapnia

Differential diagnosis

• Pulmonary embolism
• Myocardial infarction
• perforation of an aneurysm

Since death can occur within minutes, the only possible therapy - decompression - should be performed on site. Transportation, even to a nearby clinic, is medically unacceptable.

The consequences of a possibly wrong diagnosis and decompression due to this mistakenly performed decompression are disproportionate to the omission of decompression.

Performing decompression (there is no alternative therapeutic measure)::

For decompression, a long, large-caliber cannula (20 G or 1 needle) without a syringe is recommended. This should be inserted through the 2nd ICR medioklavicularly into the pleural cavity.

Due to the venous congestion it can bleed unusually strongly, but the needle should still be advanced until the thoracic cavity is reached and air escapes. As soon as even a quantity of approx. 50 - 100 ml/min of gas has been evacuated, this usually leads to immediate clinical stabilization. The cannula should be left in place until a pleural drainage can be placed.

Forecast

There are no prognostic statements specifically concerning the tension pneumothorax.

In general, the following statements apply to tension pneumothorax:

• In up to 50 % of patients with primary spontaneous pneumothorax recurrence occurs in the first year. It is therefore recommended - if the patient is a smoker - to give up smoking urgently.
• Diving should be avoided permanently. Only patients who have undergone an open surgical bilateral pneumectomy and in whom both the CT examination and the lung function show inconspicuous findings postoperatively can continue to practice this sport.
• There is no increased risk of pneumothorax in air travel compared to healthy lung patients, even after secondary pneumothorax.
• The sometimes described increased occurrence of a pneumothorax due to physical exertion could clearly not be proven in studies.

1. Gerok W et al.(2015) Internal Medicine - Reference work for the medical specialist 244
2. Herold G et al (2017) Internal Medicine 428
3. Kasper DL et al (2015) Harrison's Principles of Internal Medicine 1719
4. Köhler D et al (2010) Pneumology 190, 331
5. Loscalzo J et al (2011) Harrison's Pulmonary Medicine and Intensive Care 259
6. Stürmer KM et al (2011) Guideline polytrauma / severe injury treatment. AWMF Guideline