What is the recommended location for a needle thoracostomy (NT) to relieve a tension pneumothorax (TP)?

Optimal Location for Needle Thoracostomy in Tension Pneumothorax

For tension pneumothorax, needle thoracostomy should be performed at the 2nd intercostal space in the midclavicular line (2nd ICS-MCL), especially for left-sided pneumothoraces, while the 5th intercostal space in the midaxillary line (5th ICS-MAL) is an appropriate alternative for right-sided pneumothoraces. 1, 2

Primary Recommended Sites

First-Line Approach

• 2nd intercostal space, midclavicular line (2nd ICS-MCL):
  • Traditional and widely recommended site in clinical guidelines 2
  • Safer option for left-sided tension pneumothorax due to lower risk of cardiac injury 1
  • Average chest wall thickness at this site: 4.5 cm ± 1.1 cm 3

Alternative Site

• 5th intercostal space, midaxillary line (5th ICS-MAL):
  • Appropriate alternative, particularly for right-sided tension pneumothorax 1
  • Thinner chest wall compared to 2nd ICS-MCL (3.5 cm ± 0.9 cm vs 4.5 cm ± 1.1 cm) 3
  • Higher success rate in cadaveric studies (100% vs 57.5% at 2nd ICS-MCL) 3

Needle Selection

• Needle length: Use a minimum 7 cm needle to ensure adequate pleural penetration 1

  • Failure rates decrease by 7.76% per cm of increased needle length 1
  • Standard 5 cm needles may be inadequate, with a 32.84% failure rate for pleural penetration 1

• Gauge: 14-gauge needle is recommended 2

Anatomical Considerations

1. Chest Wall Thickness:

   • No significant difference in chest wall thickness between genders 1
   • In overweight and obese patients, the chest wall is thicker at 5th ICS-AAL than at 2nd ICS-MCL 4

2. Risk of Injury:

   • Higher injury rates at 5th anterior axillary line (5AAL) compared to 5th midaxillary line (5MAL) 1
   • Risk of cardiac injury with left-sided procedures, particularly at lateral sites 1, 5

Common Pitfalls and Caveats

1. Anatomical Identification Errors:

   • Healthcare providers frequently misidentify the correct anatomical location 6
   • Mean distance from correct location in one study was 3.12 cm 6
   • Most common error is placing the needle too inferior (93% of cases) 6

2. Procedure Failures:

   • Insufficient needle length is a common cause of failure 2
   • Catheter dislodgment is a frequent complication, particularly at the 2nd ICS 2

3. Avoiding Complications:

   • Do not wait for tracheal deviation before intervening, as it is not a reliable sign 2
   • Be aware of the risk of myocardial penetration, particularly with anterior approaches 5
   • Leave the cannula in place until a proper chest tube is inserted 2

Decision Algorithm

1. For left-sided tension pneumothorax:

   • Use 2nd ICS-MCL to minimize risk of cardiac injury 1
   • Use a 7 cm, 14-gauge needle 1, 2

2. For right-sided tension pneumothorax:

   • Either 2nd ICS-MCL or 5th ICS-MAL is appropriate 1
   • 5th ICS-MAL may have higher success rates due to thinner chest wall 3
   • Use a 7 cm, 14-gauge needle 1, 2

3. For patients with higher BMI:

   • 2nd ICS-MCL may be preferable as chest wall thickness is less at this site in overweight and obese patients 4

Remember to monitor closely for signs of recurrent tension pneumothorax after needle decompression and prepare for definitive treatment with tube thoracostomy 2.