Respiratory · Topic 4 of 19
Pneumothorax
A tall, thin young man suddenly grabs at the chest and can't breathe — breath sounds are absent on one side only.
Start here
Pneumothorax
Air collapses the lung. Simple, open or tension — the trachea and BP tell you which.
Three kinds of pneumothorax on the same chest, seen from the front. Simple: air leaks from the right lung into its pleural space and the lung partly collapses; the trachea stays in the midline and the blood pressure is normal. Open: a hole in the chest wall sucks outside air in on each breath in and blows it back out on each breath out, so no pressure builds; the lung collapses; the trachea stays midline and the blood pressure is normal. Tension: a one-way valve lets air in but not out; the trapped air collapses the lung and shoves the heart and trachea across the midline; the jugular veins distend and the blood pressure falls.
- Simple: air leaks from the lungNurse seestrachea midline, BP normal · dyspnea, sharp pain, ↓ breath soundsNurse doesoxygen; chest X-ray confirms it
- Open: a hole in the chest wallNurse seesair sucks in and blows out — trachea midline, BP normalNurse doesocclusive dressing taped on three sides
- Tension: a one-way valve traps airNurse seestrachea shifted away, BP falling, JVDNurse doesneedle decompression now — no X-ray first
Plus absent breath sounds, jugular vein distention, tachycardia · a bedside diagnosis — don't wait for the X-ray
Midclavicular line, affected side · then a chest tube (ATLS now prefers 4th–5th ICS, anterior-to-midaxillary, in adults)
Air escapes on the breath out but can't get in on the breath in
Tension pneumothorax
Obstructive shockTension pneumothorax, a chest seen from the front. A tear in the right lung acts as a one-way valve: each breath in lets air into the pleural space, and on the breath out the flap shuts so none leaves. The trapped air builds pressure that collapses the lung and shoves the heart and trachea across the midline to the other side. The shifted heart kinks and squeezes the great veins, so blood can't return to the heart: the jugular veins distend and the blood pressure falls.
- Each breath lets air in, none outNurse seessevere distress, absent breath sounds on that sideNurse doescall for help; prepare to decompress
- Heart and trachea shoved asideNurse seestrachea shifted away from the affected sideNurse doesdon't wait for one sign — act on the picture
- Blood can't return: BP fallsNurse seeshypotension, tachycardia, JVDNurse doesneedle decompression now
Needle decompression of a tension pneumothorax, a chest seen from the front. The right lung is collapsed, air fills its pleural space, and the heart and trachea are shoved to the other side. Counting down from the clavicle, the site is the 2nd intercostal space, between the 2nd and 3rd ribs, on the midclavicular line, on the affected side. The needle goes in there and the trapped air rushes out. The lung re-expands, the trachea comes back to the midline and the blood pressure rises.
- Find the siteNurse seescount down from the clavicle: 2nd ICS, midclavicular, affected sideNurse does14–16 gauge catheter, just above the rib
- Needle in: trapped air rushes outNurse seesa rush of airNurse doesa chest tube comes next
- The lung re-expandsNurse seesBP rises, trachea back to midlineNurse doesdecompression worked — reassess
Causes
Who gets itClassic exam patient: a tall, thin young man who smokes
What you'll see
SignsDiagnosis
ConfirmSimple: the chest X-ray · Tension: at the bedside
Red flags
Act nowTreatment by kind
Match the fixTension gets a needle now; the others are treated by size and symptoms
A 14–16 gauge catheter just above the rib, then a chest tube.
Don't wait for an X-raySupplemental oxygen speeds reabsorption of the pleural air.
Or needle aspiration. Recurrent: pleurodesis (sealing the pleural layers).
An open chest wound covered by a square occlusive dressing taped down on three sides, with the fourth edge left free. On each breath in, the dressing is sucked flat against the wound and seals, so no air can enter the chest. On each breath out, the free edge lifts and the trapped air escapes from under it.
Nursing priorities
In orderAir or fluid?
Percussion| Percussion | Hyperresonant |
|---|---|
| Chest tube placed | High, in front (2nd–3rd ICS) |
Teach your patient
Before dischargeTension is a bedside diagnosis. Trachea shifted and BP falling — decompress; don't wait for the X-ray.
Sources · OpenStax Medical-Surgical Nursing 11.6: Pneumothorax · Pneumothorax (StatPearls) · Tension Pneumothorax (StatPearls) · Acute Pneumothorax Evaluation and Treatment (StatPearls) · Pleural Effusion (StatPearls) · Films: the NurseSavvy learning-flow visuals. Follow your facility's protocol.
Pneumothorax
A tall, thin young man suddenly grabs at the chest and can't breathe — breath sounds are absent on one side only. Is this a simple pneumothorax that can be observed, or a tension pneumothorax where the clock is ticking?
A pneumothorax occurs when air enters the pleural space, collapsing the lung partially or completely. There are three types the NCLEX tests: spontaneous (often in tall, thin males or those with COPD, no trauma), traumatic (rib fracture, central line placement, mechanical ventilation), and tension — the life-threatening emergency. In tension pneumothorax, air enters the pleural space on inspiration but cannot escape on expiration, creating a one-way valve effect. Pressure builds rapidly, pushing the mediastinum toward the unaffected side, compressing the heart and great vessels, causing obstructive shock. Assessment findings progress predictably: absent breath sounds on the affected side, tracheal deviation away from the affected side (late and ominous), hypotension, tachycardia, jugular vein distension, and subcutaneous emphysema (crepitus under the skin). A simple pneumothorax shows decreased breath sounds, dyspnea, pleuritic chest pain, and hyperresonance on percussion. Chest X-ray confirms simple pneumothorax, but tension pneumothorax is a clinical diagnosis — you do not wait for imaging. Emergency treatment for tension pneumothorax is needle decompression at the second intercostal space, midclavicular line on the affected side, followed by chest tube insertion. Small spontaneous pneumothoraces may resolve with observation and supplemental oxygen, which accelerates reabsorption of pleural air.
Key Distinctions
Don't confuse tension pneumothorax (tracheal deviation AWAY from affected side, absent breath sounds, hypotension) with hemothorax (dullness on percussion, blood in chest). Students mix up tracheal deviation direction — it shifts AWAY from the tension side because pressure pushes structures over. Hyperresonance means air trapping (pneumothorax); dullness means fluid (effusion or hemothorax).
Clinical Pearl
Absent breath sounds + tracheal deviation + hypotension = tension pneumothorax. Don't wait for the X-ray — this triad means needle decompression NOW.
Knowledge Check
3 quick questions on the must-knows for this topic.
Which pneumothorax type is the life-threatening emergency?
Loading questions…
Go further
- Commonly confusedAsthma vs COPDReversible vs irreversible airway disease — similar wheeze, different management.
- GuideHow to Study for Med-Surg: Stop Memorizing, Start ConnectingMed-surg is the first course where memorizing stops working. Start every topic at the mechanism, climb from know-it to spot-it to act-on-it, and practice questions early at the right difficulty — with a real NGN bowtie to try in-page.
- QuizNursing study gamesSort look-alike conditions and drugs against the clock — the fast way to stop mixing them up.
Ready to practice this topic?
Get a personalized study plan built around this topic — free to try, no card needed.