A 45-year-old construction worker is brought to the emergency department after falling from scaffolding and landing on his left side. He presents with severe left-sided chest pain, shortness of breath, and decreased breath sounds on the left side. Chest X-ray reveals a pneumothorax with 40% lung collapse. What is the priority nursing intervention?
1Administer high-flow oxygen via non-rebreather mask
2Prepare for immediate chest tube insertion✓ 정답
3Position the patient in Trendelenburg position
4Obtain arterial blood gas analysis
해설
A pneumothorax with 40% lung collapse and respiratory distress requires immediate chest tube insertion to re-expand the lung and prevent tension pneumothorax. Other options are supportive but not definitive for this significant collapse.
Understanding the Clinical Scenario
This patient presents with a traumatic pneumothorax following a fall, evidenced by severe chest pain, shortness of breath, decreased breath sounds, and a chest X-ray showing 40% lung collapse. In the context of trauma, the underlying pathophysiology involves a disruption of the pleural integrity, allowing air to enter the pleural space. This accumulation of air increases intrapleural pressure, compresses the lung, and prevents effective ventilation. A collapse of this magnitude is significant and constitutes a medical emergency requiring immediate intervention to re-expand the lung and restore normal intrathoracic pressure dynamics [3,4].
Priority Intervention and Rationale
The priority nursing intervention is to prepare for immediate chest tube insertion (tube thoracostomy). The core principle in managing a large, symptomatic pneumothorax is the prompt evacuation of air from the pleural space. While administering oxygen is a critical supportive measure, it does not address the root cause of the respiratory compromise, which is the mechanical compression of the lung by the trapped air [2,3]. The systematic review and meta-analysis by Alsaigh et al. confirms that intercostal tube drainage is a definitive and effective primary management strategy for achieving lung re-expansion [3]. The case report by Aldemir similarly illustrates that in a scenario of acute, symptomatic pneumothorax, emergent tube thoracostomy leads to immediate lung re-expansion and symptom relief [2]. As a nurse, your role is to anticipate this procedure by gathering the necessary equipment (chest tube tray, drainage system, local anesthetic), positioning the patient, and providing psychological support, thereby facilitating a rapid and life-saving intervention.
Why Other Options Are Not the Priority
- Administering high-flow oxygen is an essential and immediate nursing action for any patient with respiratory distress and should be initiated concurrently. However, it is a supportive measure that increases the partial pressure of oxygen in the alveoli and can help reabsorb nitrogen from the pleural space in a small pneumothorax, but it will not mechanically re-expand a lung that is 40% collapsed due to a large volume of trapped air. The definitive treatment for a large traumatic pneumothorax is air evacuation, making preparation for this procedure the priority over supportive oxygen therapy alone [2,4].
- Positioning the patient in Trendelenburg position is contraindicated. This head-down position would shift abdominal contents upward against the diaphragm, further restricting lung expansion and exacerbating respiratory distress. The optimal position to facilitate breathing and prepare for a chest tube insertion is typically upright or semi-Fowler's.
- Obtaining an arterial blood gas (ABG) analysis provides valuable information about oxygenation, ventilation, and acid-base status. However, in an acute emergency with a clear clinical and radiographic diagnosis, performing an ABG analysis delays a critical, time-sensitive intervention. The prehospital study by Occelli et al. emphasizes the importance of timely diagnosis and management, specifically noting that clinical signs should prompt early thoracic decompression without waiting for additional diagnostic procedures that do not change the immediate need for intervention . The clinical presentation and chest X-ray provide sufficient data to proceed with the definitive treatment.
References (research sources)
[2]
Spontaneous Pneumothorax Precipitated by a Forceful Sneeze in a Young Male: A Case Report.Case reportAldemir H. (2026) · DOI: 10.7759/cureus.104902
[3]
Effectiveness of intercostal tube drainage versus other invasive approaches in initial management of pneumothorax in adults: a systematic review and meta-analysis.Meta-analysis/systematic reviewAlsaigh S, Abu Reida F, Almimoni MM, Alnajm MF, Alhojailan RA, Alhamrani M, Alharbi A, Alwadai MMH, Alotaibi AJ. (2026) · DOI: 10.5144/0256-4947.2026.61
Clinical Management Guide
Traumatic Pneumothorax with >30% Collapse
Immediate Priority: Prepare for emergent tube thoracostomy (chest tube insertion) to evacuate air from the pleural space and facilitate lung re-expansion. This is a definitive, life-saving intervention.
Supportive Care: Administer high-flow oxygen via a non-rebreather mask concurrently while preparing for the procedure to maximize oxygen saturation, but never delay the definitive treatment.
Positioning: Keep the patient in a high Fowler's or upright position if spinal injury is ruled out. Avoid Trendelenburg, which can further compromise ventilation.
Nursing Actions: Assemble chest tube insertion equipment, ensure informed consent is obtained, monitor vital signs and pulse oximetry continuously, and provide analgesia and sedation as ordered.
Post-Insertion: Connect the chest tube to a water-seal drainage system, confirm placement with a repeat chest X-ray, and monitor for complications such as re-expansion pulmonary edema or persistent air leak.
Key Safety Point
Do not delay chest tube insertion for diagnostic tests like ABGs in a symptomatic patient with a large pneumothorax. Tension pneumothorax can develop rapidly and is fatal if not immediately decompressed.
Pneumothorax — A collection of air in the pleural space causing lung collapse, which can be spontaneous or traumatic.
Tube Thoracostomy — A surgical procedure involving the insertion of a chest tube to drain air, fluid, or blood from the pleural cavity.
Non-rebreather Mask — A high-flow oxygen delivery device used for supportive care in hypoxemic patients but not definitive for pneumothorax.