You're in the back of the rig, and the radio is quiet for once. Your patient is sitting up, maybe a bit anxious, but talking in full sentences. They’ve got some pleuritic chest pain and maybe a slight decrease in breath sounds on the right side. You’re pretty sure it’s a "collapsed lung," or at least the start of one. This is exactly what it looks like when transporting a stable patient with a possible pneumothorax. It isn't always the high-octane, needle-decompression drama you see on TV. Honestly, most of the time, it’s about preventing a stable situation from turning into a nightmare at sixty miles per hour.
People think EMS is all about the "lights and sirens" rush, but with a suspected pneumothorax, vibration and rapid altitude changes are actually your enemies. If that tiny pocket of air in the pleural space decides to expand, you aren't just looking at a "stable" patient anymore. You're looking at a tension pneumothorax. That’s the stuff that keeps medics up at night.
The Reality of the "Stable" Label
Stable is a relative term in medicine. In the context of a pneumothorax, "stable" means the patient has compensated for the loss of lung volume. Their heart rate might be a little high—tachycardia is a classic sign—but their blood pressure is holding. They aren't gasping for air. Yet.
According to the American College of Chest Physicians, a small pneumothorax is often defined as a distance of less than 2 cm between the lung margin and the chest wall on an upright X-ray. But you don't have an X-ray in the back of an ambulance. You have your ears, your eyes, and your gut. You’re looking for that subtle tracheal deviation that everyone talks about but almost nobody actually sees until it’s far too late.
The mechanism matters. Did they just have a central line placed? Did they spontaneously pop a bleb because they’re a tall, thin teenager who grew too fast? Or was it blunt trauma from a steering wheel? Knowing the "why" helps you predict the "what next."
Assessment Nuances Most People Miss
A lot of providers just slap on a pulse ox and call it a day. That’s a mistake. While transporting a stable patient with a possible pneumothorax, your pulse oximetry might stay at 96% or 98% for a long time because the other lung is working overtime.
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You need to watch the work of breathing. Look at the neck muscles. Are they tensing? Is the patient leaning forward? These are the "quiet" signs of compensation. If they start getting restless or agitated, don't just assume they're "difficult" or anxious about the bill. Hypoxia manifests as irritability long before the skin turns blue.
Don't forget the skin. Subcutaneous emphysema—that "Rice Krispies" crunching feeling under the skin—is a dead giveaway that air is escaping the lung and traveling where it shouldn't. If you feel that on the neck or chest, you’ve basically confirmed your diagnosis without a single scan.
Why Position and Oxygen Matter More Than You Think
We used to give everyone high-flow oxygen. Now, we’re a bit more surgical about it. For a stable patient, if their saturations are fine, you might wonder if oxygen is even necessary. Actually, the British Thoracic Society and other experts often suggest high-flow oxygen for pneumothorax patients not just for "air," but to speed up reabsorption.
It’s a bit of physics. By breathing high concentrations of oxygen, you lower the partial pressure of nitrogen in the blood. This creates a gradient that helps the trapped nitrogen in the pleural space dissolve back into the blood faster. It basically helps the body "suck" the collapsed lung back into place.
Put them in a Fowlers position. Sitting up. It lets gravity help the lung expand and keeps the abdominal organs from pushing up against the diaphragm. It’s simple, but it works.
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The Danger of the "Bump"
When you are transporting a stable patient with a possible pneumothorax, the road is your biggest variable. Every pothole and every sharp turn is a physical stressor on that pleural seal.
If you’re in a rural area and have to fly the patient, you have a whole different set of problems. Boyle’s Law is a literal killer here. As altitude increases, atmospheric pressure decreases, and that pocket of air in the chest will expand. A stable 10% pneumothorax at sea level can become a life-threatening 30% or 40% pneumothorax at 5,000 feet. This is why flight crews are so aggressive about chest tubes or venting before they even lift off. Even in a ground rig, a long transport over a mountain pass requires the same level of vigilance.
Monitoring for the "Shift"
The transition from stable to unstable is often fast. You’re looking for the classic "Beck's Triad" or signs of tension, but usually, the first thing you’ll see is a drop in the End-Tidal $CO_2$ or a sudden spike in heart rate.
- Keep the needle ready. You don't want to be fumbling for a 14-gauge catheter when the patient's blood pressure bottoms out. Have your decompression kit on the bench next to you.
- Re-evaluate breath sounds every 5 minutes. Is the quiet side getting quieter?
- Watch the jugular veins. Distension is a late sign, but in a thin patient, it’s a huge red flag that pressure is building up and preventing blood from returning to the heart.
Practical Steps for the Transport
If you’re the one in the back, your job is observation and preparedness. Forget the paperwork for a minute. Focus on the person.
- Avoid Positive Pressure Ventilation (PPV) if possible. If the patient is breathing on their own and staying stable, keep it that way. Bagging a patient with a pneumothorax is like blowing up a balloon that has a hole in it—you're just pumping air into the chest cavity and forcing a tension pneumothorax to happen faster.
- Auscultate in the right places. Don't just listen to the front. Get the mid-axillary line (the armpit area). That’s often where you’ll hear the difference first.
- Communicate with the driver. Tell them to take the corners like they have a literal bomb in the back. Smooth is fast.
What to Tell the Receiving Facility
When you call in your report, be specific. Don't just say "possible pneumothorax." Tell them why you think so. "Patient has diminished sounds on the left, 2/10 sharp pain, but remains hemodynamically stable with a heart rate of 90 and $SpO_2$ of 95% on 15L NRB."
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This helps the ER prep the right room. They’ll have the ultrasound (eFAST) ready the second you roll through the doors.
Actionable Insights for Clinicians
Managing this isn't about being a hero; it's about being a scientist.
First, trust your physical exam. If the chest looks asymmetrical when they breathe, believe your eyes. Second, maintain a high index of suspicion in trauma. Just because they don't have a "sucking chest wound" doesn't mean the lung isn't leaking air internally.
Third, understand the limitations of your equipment. Pulse oximetry is a lagging indicator. By the time the number drops, the patient has been struggling for several minutes. Use capnography if you have it; a widening gap between the patient's effort and their $CO_2$ output can signal a problem.
Finally, always have a "Plan B." If the patient "tensions" during transport, you must be prepared to perform a needle thoracostomy immediately. Know your landmarks—the second intercostal space at the mid-clavicular line is the old standard, but many now prefer the fourth or fifth intercostal space at the anterior axillary line because the chest wall is thinner there for most people.
Stay focused on the patient's trend. A "stable" patient is only stable until they aren't. Your job is to make sure that transition happens in a hospital hallway, not on the side of a highway.