Needle Thoracostomy: Is it Time to Switch to a Longer Needle?

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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.[1] 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.[2]

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.

Needle length
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.[1] 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.[1]

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.[10] 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.[10]

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]

Needle location
A 2015 meta-analysis compared different chest wall sites for NT.[3] 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.[10] 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.[12] This finding must be considered during prehospital ground or air transportation in the civilian arena.

Conclusion
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.

References:

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.

3. Laan DV, Vu TD, Thiels CA, et al. 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.

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

5. Ball CG, Wyrzykowski AD, Kirkpatrick AW, et al. Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Can J Surg. 2010 Jun;53(3):184-8.

6. Carter TE, Mortensen CD, Kaistha S, Conrad C, Dogbey G. Needle Decompression in Appalachia Do Obese Patients Need Longer Needles? West J Emerg Med. 2013 Nov;14(6):650-2.

7. Stevens RL, Rochester AA, Busko J, et al. Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography. Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7.

8. Inaba K, Ives C, McClure K, et al. Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Arch Surg. 2012 Sep;147(9):813-8.

9. Powers WF, Clancy TV, Adams A, West TC, Kotwall CA, Hope WW. Proper catheter selection for needle thoracostomy: a height and weight-based criteria. Injury. 2014 Jan;45(1):107-11.

10. Chang SJ, Ross SW, Kiefer DJ, et al. Evaluation of 8.0-cm needle at the fourth anterior axillary line for needle chest decompression of tension pneumothorax. J Trauma Acute Care Surg. 2014 Apr;76(4):1029-34.

11. Zengerink I, Brink PR, Laupland KB, Raber EL, Zygun D, Kortbeek JB. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? J Trauma. 2008 Jan;64(1):111-4.

12. Beckett A, Savage E, Pannell D, Acharya S, Kirkpatrick A, Tien HC. Needle decompression for tension pneumothorax in Tactical Combat Casualty Care: do catheters placed in the midaxillary line kink more often than those in the midclavicular line? J Trauma. 2011 Nov;71(5 Suppl 1):S408-12.