Tension pneumothorax: a case-based approach

The presentation

Imagine an adult who has recently had a chest injury — perhaps a fall, a car crash or a broken rib — or who has a lung condition. Quite suddenly they develop severe breathlessness that gets rapidly worse, along with sharp chest pain on one side. Within minutes they look frightened and are gasping for air, their lips and skin may turn a dusky, bluish colour, their heart is racing, and they feel faint or become confused. One side of the chest may seem to move less or look more swollen. This is very different from ordinary breathlessness that builds slowly or eases with rest — it is dramatic, worsening by the minute, and the person is visibly and severely unwell. This alarming pattern of sudden, rapidly worsening breathlessness with collapse is what should trigger an immediate emergency call.

What is happening in the chest

Each lung sits inside the chest surrounded by a thin space. In a pneumothorax, air leaks into this space through a hole in the lung or chest wall, and the lung partly collapses. Usually this is uncomfortable but stable. In a tension pneumothorax, the leak acts like a one-way valve: air is pushed into the space with each breath but cannot escape, so the trapped air builds up under rising pressure. This growing pressure not only flattens the affected lung but also pushes on the heart and the big blood vessels and squashes the other lung, so the heart cannot pump properly and the body is starved of oxygen. Because the pressure keeps rising with every breath, the situation deteriorates fast, which is exactly why a tension pneumothorax is a true, minute-by-minute emergency.

When to call 999

Call 999 immediately if someone develops sudden, severe and rapidly worsening breathlessness with sharp chest pain, especially after a chest injury or in someone with lung disease, and even more so if they look pale or blue, are gasping, have a racing heart, feel faint, become confused or collapse. Do not wait to see whether it settles — a tension pneumothorax gets worse by the minute and can be fatal. Tell the call handler clearly that the person is struggling to breathe and getting worse, and mention any recent injury. While waiting, help them into whatever position lets them breathe most easily, usually sitting up, keep them calm and still, loosen tight clothing, and stay with them. If they become unresponsive and stop breathing normally, follow the 999 operator's instructions, which may include starting CPR.

How it is treated

A tension pneumothorax is a medical emergency treated by paramedics and hospital staff, not something that can be dealt with at home. The life-saving step is to release the trapped air quickly so the pressure falls and the heart and lungs can work again; this is done urgently by trained clinicians. Afterwards, a tube is usually placed into the chest to let the air keep draining and allow the lung to re-expand, and the person is monitored closely and given oxygen and other support as needed. The underlying cause, such as an injury or a lung problem, is then treated. Because everything depends on speed, the single most important thing a bystander can do is recognise the emergency and call 999 straight away, giving the person the best chance of rapid, life-saving treatment.

The safe pathway

The practical rule is simple: sudden, severe, worsening breathlessness with chest pain and signs of collapse is always an emergency, whatever the cause. You do not need to know whether it is a tension pneumothorax, a heart problem or something else — the response is the same: call 999 at once. This is especially important after any chest injury, or in someone with known lung disease who suddenly deteriorates. Do not attempt any procedure yourself, do not give food or drink, and do not delay to look things up. Keep the person calm, help them into the position that eases their breathing, and stay with them until help arrives. Tension pneumothorax is uncommon, but because it can kill within minutes, recognising the pattern and acting fast is what saves lives.