How To Do Needle Thoracostomy

Tension pneumothorax Pneumothorax (Tension) Tension pneumothorax is accumulation of air in the pleural space under pressure, compressing the lungs and decreasing venous return to the heart. (See also Overview of Thoracic Trauma.) Tension... read more that must be decompressed before tube thoracostomy can be done

None

Pulmonary or diaphragmatic laceration

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

Bleeding

Infection

Pneumothorax Pneumothorax Pneumothorax is air in the pleural space causing partial or complete lung collapse. Pneumothorax can occur spontaneously or result from trauma or medical procedures. Diagnosis is based on clinical... read more (if the procedure was done because of falsely suspected pneumothorax)

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

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

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.

Patient should be supine, lying on the back.

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 How To Do Tube and Catheter Thoracostomy Surgical tube thoracostomy is insertion of a surgical tube into the pleural space to drain air or fluid from the chest. Pneumothorax that is recurrent, persistent, traumatic, large, under tension... read more as soon as possible.

Chest x-ray should be done to confirm expansion of the lung and proper placement of the chest tube.

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

After removing the needle, the catheter may become blocked due to kinking. Kinking is especially likely with smaller catheters, including 14 and 16 gauges. Some sources recommend using a larger 10-gauge needle and catheter ( 1–3 References Needle thoracostomy, also called needle decompression, is insertion of a needle into the pleural space to decompress a tension pneumothorax. Needle thoracostomy is an emergency, potentially... read more ).