Pneumothorax: Types, Assessment, and Nursing Management

This note reviews pneumothorax — air in the pleural space that causes partial or complete lung collapse. It covers the four main types, the pathophysiology, recognition of a tension pneumothorax (a true emergency), and the nursing care of chest tubes, which are central to safe management on the medical-surgical and critical care floors.

What Is Pneumothorax?

• Pneumothorax is the presence of air in the pleural space between the visceral and parietal pleura.
• Air accumulation causes partial or complete collapse of the lung.
• It occurs when air leaks from the lung or enters through the chest wall.

Types of Pneumothorax

• Spontaneous — Rupture of a small bleb or bulla; no trauma; classically seen in tall, thin young men.
• Traumatic — Penetrating or blunt chest trauma (rib fractures, stab or gunshot wounds).
• Iatrogenic — Caused by a medical procedure (central line placement, thoracentesis, lung biopsy).
• Tension — Air enters but cannot exit; life-threatening; causes mediastinal shift.

Pathophysiology

• Air enters the pleural space through a defect in the visceral or parietal pleura.
• The lung recoils away from the chest wall due to loss of negative pressure.
• Lung volume decreases, causing hypoventilation and hypoxemia.
• In tension pneumothorax, air continues to enter but cannot exit.
• Pressure builds, shifting the mediastinum to the opposite side.
• This compresses the contralateral lung and reduces venous return.

Clinical Presentation

Symptoms

• Sudden sharp chest pain that worsens with deep breathing or coughing.
• Dyspnea, ranging from mild to severe depending on size.
• Non-productive cough may be present.

Signs on Examination

• Decreased or absent breath sounds on the affected side.
• Hyperresonance to percussion on the affected side.
• Tachypnea and tachycardia.
• Subcutaneous emphysema may be felt as crackling under the skin.

Tension Pneumothorax Signs (Emergency)

• Severe respiratory distress.
• Tracheal deviation away from the affected side.
• Distended neck veins (JVD).
• Hypotension and tachycardia.
• Absent breath sounds and hyperresonance on the affected side.

Diagnostic Tests

• Chest X-ray — Confirms diagnosis; shows visible pleural line, absence of lung markings, and mediastinal shift in tension pneumothorax.
• Ultrasound — Rapid bedside diagnosis; absence of lung sliding.
• CT chest — Provides detailed anatomy; identifies blebs or underlying lung disease.

Management

Simple Pneumothorax (Small, Stable)

• Small pneumothorax may resolve spontaneously with observation.
• Supplemental oxygen helps reabsorb air from the pleural space.
• Patient may be discharged with follow-up if stable.

Large or Symptomatic Pneumothorax

• Needle aspiration removes air via a small catheter.
• Chest tube insertion (tube thoracostomy) placed in the pleural space.
• Chest tube connects to a water seal drainage system.

Tension Pneumothorax (Emergency)

• Immediate needle decompression is required — before chest X-ray.
• Insert a large-bore (14-gauge) needle in the second intercostal space, midclavicular line.
• A "whoosh" of air confirms entry into the pleural space.
• This converts tension pneumothorax to simple pneumothorax.
• Follow with chest tube insertion for definitive management.

Recurrent Pneumothorax

• Pleurodesis chemically or surgically obliterates the pleural space.
• Video-assisted thoracoscopic surgery (VATS) removes blebs and performs pleurodesis.

Chest Tube Management

Purpose

• Remove air or fluid from the pleural space.
• Restore negative pressure.
• Allow the lung to re-expand.

Water Seal Drainage System

• Collection chamber — collects fluid or air.
• Water seal chamber — acts as a one-way valve preventing air from re-entering.
• Suction control chamber — regulates negative pressure.

Nursing Care

• Keep the drainage system below chest level at all times.
• Ensure all connections are tight and taped.
• Monitor for tidaling (fluid movement with respirations) — indicates patency.
• Monitor bubbling in the water seal chamber: intermittent is normal; continuous indicates an air leak.
• Monitor drainage amount, color, and character.
• Assess insertion site for redness, drainage, or crepitus.
• Encourage deep breathing and coughing to promote lung expansion.
• Do not clamp the chest tube unless ordered.
• Keep a sterile occlusive dressing at the insertion site.
• Prepare for removal when the lung is fully re-expanded on chest X-ray.

Complications

• Tension pneumothorax — the most dangerous complication.
• Recurrent pneumothorax — occurs in up to 50% of spontaneous cases.
• Hemothorax — may accompany traumatic pneumothorax.
• Infection or empyema.
• Re-expansion pulmonary edema after rapid lung expansion.

Nursing Assessment

• Monitor respiratory rate, depth, and effort continuously.
• Auscultate breath sounds bilaterally.
• Assess oxygen saturation and titrate oxygen as needed.
• Watch for signs of tension pneumothorax: tracheal deviation, hypotension, JVD.
• Assess the chest tube drainage system for proper function.
• Monitor for subcutaneous emphysema around the insertion site.

Nursing Interventions

• Position the patient in high-Fowler's to facilitate breathing.
• Administer oxygen to maintain SpO₂ above 92%.
• Assist with needle decompression or chest tube insertion.
• Monitor the chest tube drainage system continuously.
• Encourage deep breathing and incentive spirometry.
• Administer pain medication as ordered to promote deep breathing.
• Report any signs of tension pneumothorax immediately.

Patient Teaching

• Explain the purpose of the chest tube and drainage system.
• Teach the patient to report increased chest pain or shortness of breath.
• Instruct the patient to keep the drainage system below chest level.
• Explain that deep breathing and coughing help the lung re-expand.
• Teach signs of complications to report: fever, drainage from the site, increased pain.

Common NCLEX Traps

• Tension pneumothorax causes tracheal deviation AWAY from the affected side.
• Needle decompression → second intercostal space, midclavicular line.
• Chest tube → fourth or fifth intercostal space, midaxillary line.
• Do not clamp a chest tube for transport unless ordered.
• Continuous bubbling in the water seal chamber = air leak.
• Tidaling is normal and indicates the tube is patent.
• Subcutaneous emphysema is air under the skin; monitor but usually harmless.
• Spontaneous pneumothorax is more common in tall, thin young men.
• Mechanical ventilation increases the risk of tension pneumothorax.
• Never remove a chest tube without an order and chest X-ray confirmation.

Key takeaways

• Pneumothorax = air in the pleural space causing lung collapse; types are spontaneous, traumatic, iatrogenic, and tension.
• Classic findings: sudden sharp chest pain, dyspnea, decreased/absent breath sounds, and hyperresonance on the affected side.
• Tension pneumothorax is a life-threatening emergency — look for tracheal deviation, JVD, and hypotension; treat with immediate needle decompression at the 2nd intercostal space, midclavicular line, before X-ray.
• Chest tubes are inserted at the 4th–5th intercostal space, midaxillary line; keep the drainage system below chest level and never clamp unless ordered.
• Drainage system clues: tidaling = patent, continuous bubbling = air leak.
• Position in high-Fowler's, maintain SpO₂ > 92%, and encourage deep breathing to promote lung re-expansion.