From the Guidelines
Needle decompression is indicated for EMS providers when a patient presents with a suspected tension pneumothorax requiring immediate intervention, characterized by signs such as progressive difficulty breathing, attenuated or absent breath sound on the side of the injury, elevated chest wall, and hypotension, as identified in the study by Zong et al. 1.
Indications for Needle Decompression
The primary indications for needle decompression include:
- Progressive respiratory distress with signs of tension pneumothorax
- Decreased or absent breath sounds on the affected side
- Hypotension
- Distended neck veins
- Tracheal deviation away from the affected side (although no tracheal deviation was observed in cases of tension pneumothorax in the study by Chen et al. cited in 1)
- Oxygen-resistant cyanosis
Procedure for Needle Decompression
The standard approach involves:
- Inserting a large-bore needle (typically 14-16 gauge, with a recommended length of 3.25-in.-long or 8.25 cm) into the second intercostal space at the mid-clavicular line on the affected side, as recommended by the Committee for Tactical Emergency Casualty Care (C-TECC) 1
- Alternatively, inserting the needle at the 4th-5th intercostal space at the anterior axillary line
- Inserting the needle just over the top of the rib to avoid the neurovascular bundle
- Confirming successful decompression with a rush of air upon insertion
Importance of Needle Decompression
Needle decompression is a critical temporizing measure until definitive treatment with chest tube placement can be performed at the hospital, as it can relieve the pressure buildup in the pleural space that is compressing the lung and potentially causing mediastinal shift, which can impair cardiac output and venous return, as noted in the study by Zong et al. 1.
Diagnosis of Tension Pneumothorax
Diagnosis of tension pneumothorax can be aided by the use of hand-held, miniaturized B-mode ultrasound instruments, which have been shown to have high sensitivity and specificity in the diagnosis of tension pneumothorax, as reported in the study by Zong et al. 1.
Post-Procedure Care
After needle decompression, it is essential to monitor the patient closely for signs of tension pneumothorax and to consider tube thoracostomy if necessary, as noted in the study by Chen et al. cited in 1.
From the Research
Indications for Needle Decompression
- Abnormal vital signs, including systolic blood pressure (SBP) <100 mmHg, heart rate (HR) <60 or >100 beats/minute, respiratory rate (RR) <12 or >20 breaths/minute, and oxygen saturation (SpO2) <93% are indications for needle decompression 2
- Tension pneumothorax is a life-threatening condition that requires immediate management with needle decompression, followed by the insertion of an intercostal chest drain 3
- Hemodynamic instability or severe respiratory insufficiency are also indications for needle decompression 4
Patient Selection and Procedure
- Proper patient selection for needle decompression includes the presence of decompensated shock, respiratory distress, and diminished breath sounds 5
- The procedure should be performed with caution, taking into account patient-specific factors, such as chest wall thickness and the potential risk of cardiac injury 3
- A 7 cm needle may be appropriate for decompression of right-sided tension pneumothorax at either the 5th intercostal space along the midaxillary line or the 2nd intercostal space along the midclavicular line 3
Post-Procedure Management
- After needle decompression, patients should be carefully monitored, and portable chest radiography should be promptly obtained to confirm the diagnosis 4
- Tube thoracostomy may not be required in all cases, and the decision to perform it should be based on clinical indications, such as air or blood on chest radiography or computed tomography of the chest 6