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Author: Jake Toy, MSIII
Western University of Health Sciences
Needle thoracostomy (NT) is a lifesaving procedure often utilized in pre-hospital settings and emergency departments (ED), and is indicated in cases of tension pneumothorax. Placement of a needle catheter into the pleural space allows for emergent decompression, resulting in restored and/or increased venous return to the right atrium. Placement of a chest tube is the definitive management of a tension pneumothorax following both a successful or failed needle placement. Advance Trauma Life Support (ALTS) guidelines recommend the use of a 14-gauge 5 cm (approx. 2 in) angiocatheter placed in the 2nd intercostal space, midclavicular line (ICS-MCL), inserted at a perpendicular angle to the skin.
Recent retrospective reviews and radiologic-based analyses have suggested a high relative NT failure rate when comparing different needle sizes and needle insertion locations.[1, 3-8] In order to perform the procedure successfully, the needle must be of adequate length to transverse the chest wall and enter the pleural space. Failure rates with a 5 cm needle have been demonstrated between 4% to 50%, and up to 65% with a 3.2 cm (approx. 1.25 inch) needle.[3, 5] These studies addressed varying needle lengths in multiple chest wall sites in order to determine the optimal overall NT technique in regards to efficacy and safety.
In 2016, a retrospective review of 91 NTs performed on 70 trauma patients compared the effectiveness of a 5 cm versus 8 cm (approx. 3.25 inch) angiocatheter placed in the 2nd ICS-MCL. Efficacy was measured by clinical improvement. Patients who underwent NT with a needle length of 8 cm versus 5 cm noted a significant increased efficacy (83% vs 41% respectively). No complications were documented in either group. Radiographic analysis in this study noted that body mass index (BMI) was correlated with an increased chest wall thickness, a finding also consistent in other investigations.[1, 6, 8, 9] Interestingly, BMI ≥30 was not associated with decreased NT efficacy.
Additionally, a 2014 retrospective radiologic analysis of 100 trauma patients calculated chest wall thickness from chest computed tomography (CT) and predicted improved theoretical NT efficacy with increased needle length. When comparing 8 cm and 5 cm needle length, theoretical NT efficacy was noted at 96% and 66-81% respectively. Improved efficacy was observed irrespective of anatomical site (4th ICS-anterior axillary line (AAL) or 2nd ICS-MCL). The theoretical risk of injury at any location after measuring the distance to vital structures on imaging was 0% with a 5cm needle and 6% to 9% with an 8 cm needle. The most common sites of injury with an 8 cm needle based on distance to vital structures were the right atrium and left ventricle; however, it must be recognized that poor technique, a shallow angle of entry as opposed to a perpendicular angle of entry (proper technique), would also play a factor in the simulated increased risk of injury to vital structures.
Multiple similar studies have noted increased efficacy with utilization of a longer needle.[4-6] Notable recommendations from these studies also include: Longer needle length for women[4, 11] and consideration of BMI when choosing needle length.[6, 9]
A 2015 meta-analysis compared different chest wall sites for NT. Evidence from observational studies compared 5 cm angiocatheter placement in the 2nd ICS-MCL versus the 4th/5th ICS-AAL and 4th/5th ICS mid-axillary line (MAL) and determined that the 4th/5th ICS-AAL had the lowest predicted failure rate of NT. Mean failure rates were as follows: 38% at the 2nd ICS-MCL, 31% at the 4th/5th ICS-MAL, and 13% at the 4th/5th ICS-AAL. These findings are supported by analyses of chest wall thickness based on chest CT, which have observed that the 5th ICS-AAL is the thinnest region of the chest (1.3cm thinner on average than at the 2nd ICS-MCL).[8, 10]
Yet despite these findings, it may be important to consider evidence, which reported that an 8 cm needle has an efficacy greater than 96% based on chest wall thickness at all anatomical sites. In this report, there were no statistically significant differences in NT rates based off radiographic imaging between the 4th ICS-AAL and 2nd ICS-MCL.
One additional consideration regarding MAL needle placement is the potential higher risk of catheter kinking or occlusion during transport based on the relative lateral location in compared to a MCL needle placement. Occlusion of a successfully placed angiocatheter may result in the reaccumulation of tension pneumothoraces. A simulated NT with a 14 gauge, 1.5 inch angiocatheter placed in the MCL versus the MAL demonstrated an increased incidence of partial or temporary occlusion in patients transported on military stretchers. This finding must be considered during prehospital ground or air transportation in the civilian arena.
NT with an 8 cm needle has a relatively high, predicted success rate and optimal safety profile in all sites in comparison to a 5 cm needle.[1, 10] Recently, the Committee for Tactical Combat Casualty Care, and the Pre-hospital Trauma Life Support: Military Edition recommend the utilization of a 14-gauge 8cm angiocatheter placed in the 2nd ICS-MCL or 4th/5th ICS-AAL or MAL for military NT.[1, 3] As is consistent historically with military emergency care techniques and protocols, civilian emergency care guidelines (including ATLS) may soon adapt these recommendations. At present, more research and prospective, large-scale trials may be needed in order to demonstrate the clinical effectiveness and safety of 8 cm needles in the civilian setting.
1. Aho JM, Thiels CA, El Khatib MM, et al. Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter. J Trauma Acute Care Surg. 2016 Feb;80(2):272-7.
2. Advanced trauma life support (ATLS(R)): the ninth edition. J Trauma Acute Care Surg. 2013 May;74(5):1363-6.
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