Pneumothoraces secondary to underlying pulmonary pathology, trauma, or percutaneous procedures are always at risk of increasing in size and developing tension in positive-pressure ventilation. In general, all such collections should be drained. Exceptions may be small rims of air, thought to be insignificant, or small residual collections after a partially successful drainage procedure.
There is usually little debate on the need for drainage of a pneumothorax. Drainage should follow as soon as possible after identification of clinical signs of its significance. Delay in diagnosis or therapy may lead to catastrophic tension pneumothorax ( Fig, 1). Suspicion of pneumothorax in a severely compromised patient mandates immediate speculative pleural space decompression. Although we do not encourage the insertion of small intercostal cannulas, preferring formal chest drain insertion, temporary cannulation may prove to be lifesaving. Treatment should be based on clinical signs. Mortality from tension pneumothorax is much lower (7 versus 31 per cent) if treatment is based on clinical signs rather than delayed until radiographic diagnosis is confirmed ( Steier ef a/ 1974).
Fig. 1 Bilateral tension pneumothorax despite pleural drainage on both sides. Note the compressed mediastinal and cardiac structures. Bilateral subcutaneous emphysema is also present.
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