Note: The following information is presented for informational purposes only. This may not be best or applicable to every patient in every circumstance; professional medical advice for a particular circumstance or patient, when available, is always best.
A pneumothorax is a condition where air collects around the lung. This causes the lung to become less effective for respiration. The amount of distress the patient is experiencing depends on the amount of air collecting around the lung and the patient’s baseline lung function. The air around the lung can arise from either a chest wound allowing outside air to get sucked into the area around the lung (a “sucking chest wound”), or from the lung tissue itself, from spontaneous rupture of weakened spot on the surface of lung or from sharp ends of broken ribs that may puncture the lung.
Identifying a Pneumothorax
Identification of a pneumothorax in a health care facility is often seen on a chest x-ray or other imaging studies. In primitive conditions, a pneumothorax can still be identified, without the fancy imaging studies. Identifying a pneumothorax is of importance because it can become life threatening. The goal in treatment is to facilitate the evacuation of air collecting around the lung, or prevent the entry of more air collecting around it. A small pneumothorax may be watched with serial chest x-rays and sometimes resolves on its own. Large or worsening pneumothorax reveal the patient to have pain on the affected side and be short of breath. The affected side has diminished or absent breath sounds (when listened with a stethoscope or ear to the chest).
If someone has a chest wound where you can hear air rushing through the wound, then there is an open pneumothorax. The goal is to keep the air from entering the chest through the wound by applying a dressing which is air impermeable, like a piece of foil or saran wrap which is taped on 3 sides. Air from within the chest can exit through this dressing but the valve like dressing prevents outside air from entering the chest. The occlusive dressing trick (taped on 3 sides) may in itself be enough to treat the open pneumothorax and may be removed after no more air can be found moving through the wound. At health care facilities a chest tube is placed for an open pneumothorax. This is where a tube is placed between the ribs and into the pocket of air around the lung. This tube is placed to suction or placed onto one way valves to evacuate the air collection and allow for re-expansion of the lung. After a few days the tube can usually be removed and an occlusive ( air tight ) dressing is placed for a few days.
Blunt chest injury with broken ribs puncturing the lung surface or spontaneous rupture of weakened area on the surface of the lung can produce a closed pneumothorax. There is no sucking open wound in this example. If this patient was in distress, a chest tube would need to be placed to remove the air collection around the lung. A large bore IV needle may be used in emergencies and a sterile rubber tube made from the finger of a glove can be attached to form a one way Heimlich valve.
The most worrisome complication from a pneumothorax is that of enlargement with worsening respiratory function. Sometimes the air collection can become so large that it pushes against the good unaffected lung and heart. This is called a tension pneumothorax. The patient is in severe and often worsening respiratory distress. Placement of any kind of tube into the side of the chest with the air under pressure offers immediate relief. A one way rubber glove finger valve may then be attached for better effect and removed in a few days.
Any tubes to be placed into the chest are best placed on the sides and above the level of the nipple. The tube should slide over the top of the rib to avoid the blood vessels located at the bottom edge of the ribs.
The benefit of understanding and knowing how to treat a pneumothorax is that it’s one of the few life-threatening problems that could be reasonably treated in an austere environment with simple tools. While a pneumothorax is always best treated by a medical professional, you may not always have that available. The information above should help you to identify a pneumothorax, its type, and offer initial treatment in a ditch situation.
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