Bilateral tube thoracostomy to preclude fatal tension pneumothorax in patients with acute respiratory insufficiency.

Two patients with acute respiratory insufficiency requiring prolonged mechanical ventilation are described. Both patients developed fatal unilateral tension pneumothoracies after the respiratory insufficiency appeared to be improving. The pneumothorax in each patient appeared to be the result of high inspiratory pressures resulting from high tidal volumes and positive end expiratory pressure. Currently, we recommend bilateral chest tube thoracostomies for those patients with inspiratory pressures greater than 40 cm H2O as a prophylaxis against this fatal complication.