Where is a needle decompression (ND) placed for a tension pneumothorax?

From the Guidelines

A needle decompression for tension pneumothorax should be placed in the second intercostal space at the midclavicular line on the affected side. This procedure is a life-saving intervention that requires immediate action to relieve the pressure buildup in the pleural space. The use of a large-bore catheter (14-16 gauge) inserted perpendicular to the chest wall, just above the rib, is recommended to avoid the neurovascular bundle that runs below each rib [ 1 ].

The midclavicular approach is traditionally preferred due to less overlying muscle and fat tissue, though the lateral approach may be safer in patients with larger chest walls and reduces the risk of injury to internal mammary vessels. It is essential to use a cannula of adequate length, at least 4.5 cm, to ensure proper placement and function [ 2 ]. After needle decompression, a chest tube should be placed as soon as possible for definitive management, as the catheter may become occluded or dislodged.

Some key points to consider when performing a needle decompression include:

• Using a large-bore catheter to ensure adequate airflow and relief of pressure
• Inserting the catheter perpendicular to the chest wall to avoid complications
• Placing the catheter in the second intercostal space at the midclavicular line, or alternatively at the 4th or 5th intercostal space at the anterior axillary line
• Securing the catheter in place and monitoring the patient closely for signs of recurrence or complications
• Repeating the needle thoracentesis or performing tube thoracostomy if symptoms of tension pneumothorax reoccur [ 1 ].

From the Research

Needle Decompression Placement

The placement of a needle decompression (ND) for a tension pneumothorax is a critical procedure that requires careful consideration of the optimal anatomical location.

• The traditional location for ND is the second intercostal space in the midclavicular line (ICS2-MCL) 3, 4, 5.
• However, recent studies have suggested that the fifth intercostal space in the midaxillary line (ICS5-MAL) may be a more effective location for ND, with higher success rates and lower failure rates 3, 6, 5.
• The choice of location may depend on the individual patient's anatomy and the specific clinical situation, with some studies suggesting that the ICS2-MCL may be more suitable for certain patients, such as those with a higher body mass index (BMI) 4.
• The use of point-of-care ultrasound (POCUS) has been proposed as a method to determine the optimal location for ND, by measuring the distance from the skin to the pleura at different locations 6.

Anatomical Considerations

• The thickness of the chest wall at the site of needle insertion is an important factor in determining the success of ND, with thinner chest walls associated with higher success rates 3, 4, 6.
• The location of the needle insertion site in relation to the ribs and intercostal spaces is also critical, with the aim of avoiding injury to surrounding structures such as the lungs, heart, and major blood vessels 5, 7.
• The use of a longer needle may be necessary in some cases to ensure penetration into the pleural cavity, particularly in patients with a thicker chest wall 5.

Clinical Implications

• The placement of a needle decompression for a tension pneumothorax is a critical procedure that requires careful consideration of the optimal anatomical location and individual patient factors.
• Healthcare providers should be familiar with the potential complications of ND, including injury to surrounding structures and failure to achieve decompression 7.
• Further research is needed to determine the optimal approach for emergency needle decompression in tension pneumothorax, including the use of POCUS and other imaging modalities to guide needle placement 5.