From the Guidelines
The recommended location for a needle thoracostomy (NT) is the second intercostal space in the midclavicular line. This location is supported by the most recent and highest quality study, which recommends using a No. 14 puncture needle (8.25 cm in length) for needle thoracentesis at this site 1. The study also suggests that if conditions allow, a valve can be added at the end of the puncture needle. When performing the procedure, it is essential to use a large-bore catheter with adequate length to ensure penetration through the chest wall. Inserting the needle just superior to the rib can help avoid the neurovascular bundle that runs along the inferior border of each rib. After insertion, listening for a rush of air can confirm successful decompression. Some key points to consider when performing a needle thoracostomy include:
- Using a large-bore catheter (14-16 gauge) with adequate length (at least 5-8 cm for adults) to ensure penetration through the chest wall
- Inserting the needle just superior to the rib to avoid the neurovascular bundle
- Listening for a rush of air to confirm successful decompression
- Monitoring the patient closely after the procedure and repeating needle thoracentesis or performing tube thoracostomy if necessary 1. It is crucial to note that this procedure is only indicated for tension pneumothorax, a life-threatening condition requiring immediate intervention to prevent cardiovascular collapse. The development of tension pneumothorax can be heralded by a sudden deterioration in the cardiopulmonary status of the patient, and it is essential to recognize the clinical signs, including rapid labored respiration, cyanosis, sweating, and tachycardia 1.
From the Research
Location for Needle Thoracostomy
The recommended location for a needle thoracostomy (NT) is a topic of discussion among medical professionals. According to the studies, there are two main locations considered for NT:
- The 2nd intercostal space on the midclavicular line (MCL) [(2,3,4,5)]
- The 4th or 5th intercostal space in the anterior axillary line (AAL) [(2,3,4)]
Comparison of Locations
Studies have compared the efficacy and complications of NT at these locations. For example:
- A study published in 2021 found that the anterior MCL location had a low rate of efficacy and a high rate of complications, and recommended performing needle decompression laterally at the AAL 2
- A cadaver-based study published in 2011 found that needle thoracostomy was successfully placed in 100% of attempts at the 5th intercostal space, but in only 58% at the traditional 2nd intercostal position 3
- A multicenter prospective cohort study published in 2020 found that the chest wall was thinner at the 2nd intercostal space in the MCL, and that theoretical chances of successful needle decompression were higher at this location 4
Paramedic Understanding of NT Location
A study published in 2022 found that paramedics had difficulty identifying the correct anatomic site for NT, with none of the 29 paramedics identifying the exact 2nd intercostal space MCL on a volunteer 6
Catheter Length for NT
A study published in 2012 found that the mean chest wall thickness at the 2nd intercostal space in the MCL was 3.06 cm, and that over 94% of Japanese trauma patients could be treated with a 5.0-cm catheter 5 Some key points to consider when choosing a location for NT include:
- The thickness of the chest wall at the proposed location [(3,4,5)]
- The potential for complications, such as penetration of the myocardium 2
- The ease of access to the pleural space [(3,5)]