Clinical Pearl 81: What Is The Best Location for Needle Decompression of a Pneumothorax

Case: A 58 year-old male who was the restrained driver of a vehicle struck on the
driver’s side with no LOC, no airbag deployment and no other injured parties. The
patient is complaining of shortness of breath and left sided chest pain. The patient
appears to be in mild respiratory distress on arrival. During the history and while
obtaining vitals the man becomes increasingly short of breath and anxious appearing.
Initial vitals: HR: 101bpm, RR: 20, SpO2: 98% and BP: 125/80. During your physical
exam decreased breath sounds are appreciated over the left chest and no bleeding,
ecchymosis or deformities are noted. You now appreciate moderate retractions with
his inspirations, JVD, a distended left chest wall and tracheal deviation to the right
with repeat vitals: HR: 135bpm, RR: 28, SpO2: 94% and BP: 95/70.

The current Advanced Trauma Life Support (ATLS) guidelines for tension
pneumothorax recommend needle thoracostomy (NT) with a 5cm angiocatheter at
the second intercostal space (ICS2) in the midclavicular line (MCL) over the affected
side of the chest (1).

Over the past couple of decades the US military has made identifying preventable
causes of death a priority and identified tension pneumothorax as the second
leading cause of preventable death in combat behind hemorrhage from isolated limb
loss. Due to the identification of being a major cause of preventable casualties in
combat, research has been advancing on the subject of tension pneumothorax(2-4).
Research has shown that a 5cm angiocatheter may not be of adequate length to
reach the pleural space and that the ICS2-MCL may not be the best location for
needle decompression (5-8).

Studies in both civilian and military populations have shown that using a 5cm
angiocatheter results in only a 50-75% success rate in gaining access to the pleural
cavity (5,6). Autopsy studies conducted by the military in service members
demonstrated an angiocatheter of at least 8cm to penetrate the chest wall and gain
access to the pleural cavity with a 99% success rate (6,7). This need in the military
population for longer angiocatheters to increase the success rate of entering the
pleural cavity can easily be translated to the civilian population where treatment
guidelines must include all body habitus types in a population. Studies utilizing
computed tomography have shown that the area of minimal chest wall thickness to
be the fourth or fifth intercostal space (ICS4/5) at the anterior axillary line (AAL) (8).
Studies have also shown higher success rates and fewer complications utilizing the
ICS4/5-AAL when compared to the ICS2-MCL for NT (8). There may also be a
decreased chance of lung injury at the ICS4/5-AAL as compared to the ICS2-MCL
because a Pneumothorax would have to be very large to have the airspace make it
all the way to the ICS2-MCL. Although air in the pleural space from a pneumothorax
can collect anteriorly to the lung, laterally or both.

We currently recommend a 14 or 16 gauge 8cm (3.15 inch) angiocatheter at the
ICS4/5-AAL inserted perpendicular to the skin for needle decompression in
pneumothorax.
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References:

1. American College of Surgeons. Advanced Trauma Life Support ATLS Student Course Manual. The ninth edition. 2012; 119.

2. McPherson JJ, Feigin DS, Bellamy RF. Prevalence of tension pneumothorax in fatally wounded combat casualties. J Trauma. 2006;60:573-8.

3. Holcomb JB, McMullen NR, Pearse LA, et al. Causes of death in Special Operations Forces in the Global War on Terror. Ann Surg. 2007;245:986-91.

4. Mark AC, Wimberger N, Sztajnkrycer MD. Incidence of tension pneumothorax in police officers feloniously killed in the line of duty: a ten-year retrospective analysis. Prehosp Disaster Med. 2012 Feb;27(1):94-7.

5. Givens ML, Ayotte K, Manifold C. Needle thoracostomy: implications of computed tomography chest wall thickness. Acad Emerg Med. 2004 Feb;11(2):211-3.

6. Harcke HT, Pearse LA, Levy AD, Getz JM, Robinson SR. Chest wall thickness in military personnel: implications for needle thoracentesis in tension pneumothorax. Mil Med. 2007 Dec;172(12):1260-3.

7. Clemency BM, Tanski CT, Rosenberg M, May PR, Consiglio JD, Lindstrom HA. Sufficient catheter length for pneumothorax needle decompression: a meta-analysis. Prehosp Disaster Med. 2015 Jun;30(3):249-53.

8. Laan DV, Vu TD, Thiels CA, Pandian TK, Schiller HJ, Murad MH, Aho JM. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2016 Apr;47(4):797-804.