When a patient present with tension pneumothorax then it is an emergency and managing the patient immediately is necessary. Many texts say tension pneumothorax is a clinical diagnosis and treatment can be carried out without any investigation to save the patient’s life. But if investigations can be done (e.g. emergency chest X-ray) within in a few minutes, if the patient is also hemodynamically stable there is no harm in doing so and this will enable the doctor to come to a definite diagnosis.

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You must be wondering what this needle that we are talking about here. In tension pneumothorax needle thoracostomy/needle decompression is done as a life saving measure especially in closed pneumothorax. However, recently there have been some debates whether needle thoracostomy is actually an effective way in saving the patient’s life. There has not been any conclusion and still needle thoracostomy is done as a lifesaving procedure. Let us see what the equipment needed are and how needle thoracostomy is done.

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Where Do You Put The Needle For Tension Pneumothorax?

There have many debates about the anatomical location and length of the needle because of the failure rate associated with needle thoracostomy in tension pneumothorax.

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The usual practice in tension pneumothorax was to use 14-16 gauge needle (an-over the needle catheter is best), the length was 5 cm. The anatomical location to insert the needle was 2nd intercostal space mid clavicular line.

Recent studies have showed that there is a failure rate of 50-75% of needle thoracostomy when a 5 cm needle is used in the 2nd intercostal space mid clavicular line. The recent for this failure has been studied in clinical studies. These studies found out that the chest wall was smallest at the 4th and 5th intercostal space anterior axillary line, thicker at 4th and 5th intercostal space mid axillary line and thickest at 2nd intercostal space mid clavicular line. The reason for needle thoracostomy failure is due to the thick chest wall at the 2nd intercostal space mid clavicular line, therefore a 5cm needle could not reach the pleural space. Studies also have done using different length needles and 8cm needle was commonly used. However, there was high injury rate with the 8cm needle (9%).

Doctors suggest when performing a needle thoracostomy the patient’s BMI, chest wall thickness should also be considered. The needle length and the anatomical location for the needle placement should be decided wisely.

Procedure

  • Administer supplemental oxygen with a nasal cannula or by an oxygen mask.
  • Patient should be in supine position (lying on the back).
  • The area should be cleaned with an antiseptic solution such as chlorhexidine or povidone iodine. (Needle length and anatomical location can be chosen according to the hospital protocol)
  • One important point to be noted is that nerves and blood vessels run along the lower edge of each rib. Therefore the needle must be placed close to the upper edge of the rib in that intercostal space.
  • Insert the throacostomy needle, closer to the upper edge of the rib (if the needle is inserted in the 2nd intercostal space then it should be closer to the 3rd rib) at an angle of 90 degrees until a “pop” sound is heard or there is sudden decrease in resistance.
  • Listen for a rush of exiting air from the needle as the pressure is released. Also reassess the patient to see if there is any improvement.

Summary

Needle thoracostomy is done in patients who present with tension pneumothorax as a lifesaving procedure. The usual practice was to use 14-16 gauge needle (an-over the needle catheter is best), the length was 5cm. The anatomical location to insert the needle was 2nd intercostal space mid clavicular line. Due to the high failure rates studies have been done and found out that the chest wall was smallest at the 4th and 5th intercostal space anterior axillary line, thicker at 4th and 5th intercostal space mid axillary line and thickest at 2nd intercostal space mid clavicular line. When an 8cm needle was used the injuries were high. Therefore, these studies suggest the best anatomical location is the 4th or 5th anterior axillary line with a 5 cm needle.

Also Read:

Pramod Kerkar

Written, Edited or Reviewed By:

, MD,FFARCSI

Pain Assist Inc.

Last Modified On: October 10, 2018

This article does not provide medical advice. See disclaimer

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