Open Pneumothorax Management

Objectives

To guide the management of patients presenting to medical personnel with suspected open pneumothorax.

Scope

This guideline describes the management of patients presenting with an open pneumothorax.

Management of closed and tension pneumothorax are not included in this guidance, alternative CGOs are available for guidance.

This guideline does not describe surgical or critical care techniques used beyond the Emergency Department in a deployed hospital care setting.

Audience

This guideline is intended for the use of registered healthcare professionals fulfilling a general role in a forward medical locations or in an Emergency Department on deployed operations.

Initial Assessment & Management

Background/Principles

Major trauma patients should be assessed following a systematic approach utilising MARCH principles.

Open pneumothorax is a an emergency finding that should be identified during the “Respiration” assessment and must be managed urgently to prevent rapid deterioration.

In an open pneumothorax, with standard negative pressure ventilation, air preferentially enters the pleural cavity via a wound in the chest wall, rather than the lungs via the airways. This pathological air flow causes lung collapse and rapid respiratory failure. 

Simple initial interventions can prevent progressive lung collapse and allow evacuation for definitive management. Other pneumothorax CGOs can be found at the following links Needle thoracocentesis and spontaneous pneumothorax

Indications

Open pneumothorax is identified by a penetrating injury to the chest accompanied by evidence of air movement through chest wound - this may present as “sucking”, “bubbling”, “hissing” or any other form of audible, visible or palpable air movement.

The patient is likely to experience respiratory distress which may manifest as increased respiratory rate, cyanosis/low oxygen saturations and increased effort of breathing. Evidence of pneumothorax may also include asymmetrical chest movement (if unilateral), reduced air entry, surgical emphysema and increased resonance on percussion.

Management of open pneumothorax must not be delayed for full chest assessment. Any penetrating injury with suspicion of air movement through the chest wall should be immediately managed, as an emergency procedure, as detailed below.

Preparation

Manage traumatic injuries in a systematic approach in line with tactical combat casualty care guidelines. Open pneumothorax should be identified and treated in the Respiration assessment.

Fully expose the chest to complete inspection for penetrating injuries.

A full visual examination of the whole chest (including back, neck and axillae) must be completed no later than the end of the Respiration phase of assessment in all patients who have been exposed to penetrating trauma or blast injury.

A more limited examination (hands rather than eyes) is only appropriate in blunt trauma where the risk of an open wound is low.

If an open pneumothorax is identified:

• If possible place the palm of a hand over the wound to provide a temporary seal to air movement.
  
  
• Wipe away blood or any other fluids prior to application of chest seals or dressings.
  
  
• Apply a vented chest seal directly over the wound ensuring the edges extend at least 2 inches/5cm beyond the wound edges.

If there are multiple wounds:

• Only one vented chest seal needs to be applied to each side (left/right) of the chest. Place the seal over the largest wound. Other wounds on the same side can be covered with any occlusive dressing.
• Treat the two sides of the chest (left/right) separately: if there are wounds on both sides of the chest than place a vented chest seal over the largest wound on the left side AND a vented chest seal over the largest wound on the right side. All other wounds can be covered with any occlusive dressing.

Reassess after application noting that it may take several breaths for the collapsed lung to re-expand after chest seal application.

Post-Procedure Care

Moving the patient may dislodge or obstruct the vented chest seal, always reassess the patient after movement.

When available and tactical considerations allow, deliver oxygen targeted as required to maintain saturations >94% in patients with open pneumothorax.

Chest injuries are extremely painful, appropriate analgesia will facilitate effective ventilation after chest seal placement and should be delivered as a priority when clinically appropriate.

Patients with open pneumothorax are at high risk of wound infection and empyema development. Antibiotics should be given in line with current microbial guidance.

Chest seal vents may become obstructed with blood and clots with a risk of subsequent re-accumulation of air and development of a tension pneumothorax. Monitor patient closely after chest seal placement.

Any suspicion of obstructed chest seal should be managed first by “burping” the seal. To achieve this peel back the seal and with clean gauze clean away any blood or clot from the chest wall and seal vents. Following this replace the chest seal and re-assess.

Continued obstruction may cause tension pneumothorax which should be managed in line with the tension pneumothorax CGO.

Positioning

If tactical and patient considerations allow, position the conscious casualty in a sitting position or position of comfort which best allows the patient to breathe.

Unless there is a risk of spinal injury that requires the patient to be supine, patients who are unconscious or who require care on a stretcher can be positioned lying on one side with the injured side down.

Prolonged Casualty Care

An open pneumothorax represents a potentially life-threatening injury that warrants urgent evacuation to a facility equipped with a surgical capability.

If this is delayed or impossible, continue to monitor the patient closely, especially for signs of chest seal obstruction and subsequent tension pneumothorax development.

Carefully manage patient positioning as described above and ensure analgesic requirements are fully addressed - these measures are vital to prevent hypoventilation and subsequent respiratory failure.

Continue to monitor oxygen saturations with initial targets of >94%. If oxygen resources are constrained or timelines to evacuation are excessively prolonged then it may be appropriate to tolerate a lower target for oxygen saturations (for example >88%) in order to be able to continue providing a lower flow of supplementary oxygen but for a longer period.

If there is persistent respiratory distress despite appropriate analgesia and positioning, it is possible that there may be a significant residual pneumothorax despite the use of the vented chest seal; if possible an intercostal chest drain (tube thoracostomy) should be placed to resolve this. Point of care ultrasound, if available, would be a useful adjunct to confirm the diagnosis. In the absence of skills or equipment to place a formal chest drain, a thoracostomy needle with an incorporated one way valve (or attachment to a chest drainage bag) can be placed in the safe triangle on the affected side. 

Paediatric Considerations

Children are especially vulnerable to respiratory deterioration and open pneumothorax along with other chest injuries should be particularly managed without delay.

In very small children, a standard-sized vented chest seals may be too large to be used practically. In this situation occlusive dressings may be cut down to appropriate sizes to seal chest injuries, but patients must then be constantly and closely monitored as such dressings are non-vented and the patient is therefore at significant risk of developing a tension pneumothorax.