From the Guidelines
Immediate needle decompression with a cannula of adequate length, followed by insertion of a functioning intercostal tube, is the recommended treatment for tension pneumothorax. This approach is based on the British Thoracic Society guidelines for the management of spontaneous pneumothorax, which emphasizes the importance of prompt intervention in cases of tension pneumothorax 1. The guidelines recommend inserting a cannula into the second intercostal space in the midclavicular line and leaving it in place until a functioning intercostal tube can be positioned.
Key considerations in the treatment of tension pneumothorax include:
- Prompt recognition of clinical signs, such as respiratory distress, cyanosis, sweating, and tachycardia
- Administration of high-concentration oxygen to improve oxygenation
- Use of a cannula with a length of at least 4.5 cm to ensure adequate penetration of the chest wall
- Removal of air from the pleural space until the patient is no longer compromised
- Insertion of an intercostal tube into the pleural space to provide definitive management
It is essential to note that tension pneumothorax can occur rapidly and may not always be preceded by obvious clinical warning signs. Therefore, a high index of suspicion is necessary, particularly in patients on mechanical ventilators or nasal non-invasive ventilation who suddenly deteriorate or develop cardiac arrest 1. By following the recommended treatment approach, clinicians can help reduce morbidity, mortality, and improve quality of life for patients with tension pneumothorax.
From the Research
Treatment for Tension Pneumothorax
The treatment for tension pneumothorax typically involves emergency decompression using a needle thoracostomy.
- Needle thoracentesis decompression (NTD) is a recommended emergency treatment for tension pneumothorax 2.
- The procedure is usually performed in the second intercostal space in the midclavicular line or the fourth or fifth intercostal space in the anterior axillary line 2, 3.
- However, studies have shown that the success rate of NTD can be low, with failure rates ranging from 39% to 76% 4.
- The failure rate may be due to insufficient needle length, with some studies suggesting that a longer needle may be needed to penetrate the chest wall in certain population groups 3, 4.
- Alternative sites for needle decompression, such as the midhemithoracic line, have been proposed as potentially safer and more effective 5.
- New technologies, such as colorimetric capnography devices, are being developed to improve the objective assessment of successful decompression 6.
Needle Thoracostomy Techniques
- The choice of needle size and site for thoracostomy can affect the success rate of the procedure 3, 4.
- A study found that using an 8-cm catheter at the 5th intercostal space anterior axillary line may put patients at risk of iatrogenic cardiac injury 4.
- The use of a longer needle, such as a 7-cm needle, has been recommended for decompression at the midhemithoracic line 5.
- The technique of needle thoracostomy should be performed with caution, taking into account the individual patient's anatomy and the potential risks of the procedure 2, 3, 4, 5.