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How to Do Needle Thoracostomy

By Noah Lechtzin, MD, MHS, Associate Professor of Medicine and Director, Adult Cystic Fibrosis Program, Johns Hopkins University School of Medicine

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Needle thoracostomy is insertion of a needle into the pleural space to decompress a tension pneumothorax. This is an emergency, potentially life-saving, procedure that can be done if tube thoracostomy cannot be done quickly enough.



There are no absolute contraindications because this procedure should be done only in life-threatening conditions. Relative contraindications include hemodynamic stability or a bleeding disorder.


  • Pulmonary or diaphragmatic laceration

  • Intercostal neuralgia due to injury of the neurovascular bundle below a rib

  • Bleeding

  • Infection

  • Rarely perforation of other structures in the chest or abdomen


  • A 14- or 16-gauge needle (an over-the-needle catheter is best); 8-cm needles are more successful than 5-cm needles but increase the risk of injury to underlying structures

  • Sterile gown, mask, gloves

  • Cleansing solution such as 2% chlorhexidine solution

Additional considerations

  • The urgency of the procedure is determined by the patient’s condition. Hypotension suggests a more advanced tension pneumothorax requiring more urgent treatment.


  • Patient should be supine, lying on the back

Relevant anatomy

  • Neurovascular bundles are located at the lower edge of each rib. Therefore, the needle must be placed over the upper edge of the rib to avoid damage to the neurovascular bundle.

Step-by-step description of procedure and key teaching points

  • The preferred insertion site is the 2nd intercostal space in the mid-clavicular line in the affected hemithorax. However, insertion of the needle virtually anywhere in the correct hemothorax will decompress a tension pneumothorax.

  • If time permits, prepare the area at and around the insertion site using an antiseptic solution such as chlorhexidine.

  • There is rarely time to provide local anesthesia, but if there is, inject 1% lidocaine into the skin, subcutaneous tissue, rib periosteum (of the rib below the insertion site), and the parietal pleura. Inject a large amount of local anesthetic around the highly pain-sensitive periosteum and parietal pleura. Aspirate with the syringe before injecting lidocaine to avoid injection into a blood vessel. Proper location is confirmed by return of air in the anesthetic syringe when entering the pleural space.

  • Insert the thoracostomy needle, piercing the skin over the rib below the target interspace, then directing the needle cephalad over the rib until the pleura is punctured (usually indicated by a pop and/or sudden decrease in resistance).

  • After doing a needle thoracostomy, insert a chest tube as soon as possible.

Warnings and common errors

  • Depending on the thickness of the chest wall, a longer needle may be needed.

Tips and tricks

  • After removing the needle, the catheter may become blocked by kinking. Kinking is especially likely with smaller catheters, such as 14 and 16 gauges. Some sources recommend using a larger 10-gauge needle and catheter (1, 2, 3).


  • 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 80(2):272–277, 2016. doi: 10.1097/TA.0000000000000889.

  • 2. Clemency BM, Tanski CT, Rosenberg M, et al: Sufficient catheter length for pneumothorax needle decompression: A meta-analysis. Prehosp Disaster Med 30(3):249–253, 2015. doi: 10.1017/S1049023X15004653.

  • 3. Beckett A, Savage E, Pannell D, et al: 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 71(5 Suppl 1):S408–412, 2011. doi: 10.1097/TA.0b013e318232e558.

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