From the Guidelines
Immediate needle decompression with a cannula of adequate length, followed by intercostal tube placement, is the definitive treatment for tension pneumothorax. The cannula should be inserted into the second intercostal space in the midclavicular line and left in place until a functioning intercostal tube can be positioned, as recommended by the BTS guidelines for the management of spontaneous pneumothorax 1.
Key Considerations
- Tension pneumothorax is a life-threatening condition that requires prompt recognition and treatment to prevent cardiopulmonary compromise and death.
- The development of tension pneumothorax is not dependent on the size of the pneumothorax, and clinical scenario may correlate poorly with chest radiographic findings.
- Patients with tension pneumothorax typically present with rapid deterioration in cardiopulmonary status, including impaired venous return, reduced cardiac output, and hypoxaemia.
- Supplemental oxygen should be administered, and the patient should be closely monitored for vital sign improvement and respiratory status.
Procedure
- Insert a cannula of adequate length (at least 4.5 cm) into the second intercostal space in the midclavicular line to perform needle thoracocentesis for life-threatening tension pneumothorax.
- Remove air until the patient is no longer compromised, and then insert an intercostal tube into the pleural space.
- The cannula should be left in place until bubbling is confirmed in the underwater seal system to confirm proper function of the intercostal tube, as recommended by the BTS guidelines 1.
Clinical Context
- Tension pneumothorax should be suspected in patients who suddenly deteriorate or develop cardiac arrest, particularly those on mechanical ventilators or nasal non-invasive ventilation.
- The clinical status of the patient is striking, with rapid laboured respiration, cyanosis, sweating, and tachycardia, and should be promptly recognized and treated to prevent mortality and morbidity.
From the Research
Treatment for Tension Pneumothorax
The treatment for tension pneumothorax typically involves immediate decompression using a needle thoracostomy or chest tube insertion.
- Needle thoracentesis decompression (NTD) is a recommended emergency treatment for tension pneumothorax, with suitable sites including the second intercostal space in the midclavicular line and the fourth or fifth intercostal space in the anterior axillary line 2.
- The success rate of NTD varies, with one study showing an overall success rate of 59% (10 of 17) 2.
- Another study found that the failure rate of needle decompression for tension pneumothorax in trauma patients was high, with 39% to 76% of attempts failing to reach the pleural space 3.
- The use of a larger catheter, such as an 8-cm catheter, may be necessary to improve the success rate of needle decompression, but this also increases the risk of iatrogenic cardiac injury 3.
- Chest tube insertion is also a common treatment for tension pneumothorax, with recommendations including the use of a small-bore chest tube (e.g. 14 French) in stable patients and a large-bore drain (24 French or larger) in unstable patients 4.
- The insertion of chest drains has a high complication rate, and incorrect positioning of the tube is the most common complication, which can usually only be reliably detected or ruled out with a CT scan 4.
Needle Size and Placement
The size and placement of the needle are critical factors in the success of needle decompression for tension pneumothorax.
- One study found that a catheter length of 4.5 cm may not penetrate the chest wall of a substantial amount (9.9%-35.4%) of the population, depending on age and gender 5.
- Another study recommended using a needle at least 7 cm long inserted perpendicular to the horizontal plane at the level of the sternal angle using the midhemithoracic line (MHL) site, which was found to be the safest site 6.
- The use of a cannula of at least 5 cm length is also recommended for needle decompression in the case of a tension pneumothorax, directly followed by the insertion of a chest tube 4.