Needle thoracostomy

Chest wall thickness at the second intercostal space midclavicular line is on average 3.41cm in men, 3.92 cm in women, and 5.36 cm in military personnel. Up to 19.3% of men and 35% of women had an anterior chest wall thickness >4.5 cm. Several other studies have examined anterior chest wall thickness and found that it exceeds the recommended catheter length of 5cm in a significant proportion of people. The average chest wall thickness at the midaxillary line is 3.5cm and at the anterior axillary line is 2.6cm.  Notice that on average female chest walls are thicker at the midclavicular line.

In attempts at decompression on 20 fresh cadavers (5cm, 14 gauge angiocath) 100%  success was seen at the 5th intercostal midaxillary space and only 58% at the 2nd intercostal midclavicular space. Anterior decompression failed more often in women.

In a series of 142 patients, success of needle thoracostomy was confirmed by the absence of a large pneumothorax on subsequent thoracic ultrasonography or CT. Decompression using a 3.2cm catheter failed in 65%, whereas a 4.5-cm catheter had only 4% failure.

Complications for needle thoracostomy is limited to case reports. The proper anterior placement is more appropriately described as slightly lateral to the nipple line instead of trying to assess for the midclavicular line. It is suggested that lateral placement may decrease the chance of iatrogenic complications such as mamillary artery, great vessel or cardiac injury.

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.

Wax DB, Leibowitz AB. Radiologic assessment of potential sites for needle decompression of a tension pneumothorax. Anesth Analg. 2007 Nov;105(5):1385-8.

Ball CG, Wyrzykowski AD, Kirkpatrick AW, Dente CJ, Nicholas JM, Salomone JP, Rozycki GS, Kortbeek JB, Feliciano DV. Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Can J Surg. 2010 Jun;53(3):184-8.

Inaba K, Branco BC, Eckstein M, Shatz DV, Martin MJ, Green DJ, Noguchi TT, Demetriades D. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma. 2011 Nov;71(5):1099-103