Needle thoracostomy, also called needle decompression, is insertion of a needle into the pleural space to decompress a tension pneumothorax.
Needle thoracostomy is an emergency, potentially life-saving, procedure that can be done if tube thoracostomy cannot be done quickly enough.
Indications for Needle Thoracostomy
Tension pneumothorax that must be decompressed before tube thoracostomy can be done
Contraindications to Needle Thoracostomy
None
There are no contraindications because this procedure is only done because of an immediate threat to life which supersedes other considerations.
Complications of Needle Thoracostomy
Pulmonary or diaphragmatic laceration
Intercostal neuralgia due to injury of the neurovascular bundle below a rib
Bleeding
Infection
Pneumothorax (if the procedure was done because of falsely suspected pneumothorax)
Rarely, perforation of other structures in the chest or abdomen
Equipment for Needle Thoracostomy
A 14- or 16-gauge needle (an over-the-needle catheter is best); 8-cm needles are more successful than 5-cm needles but increase the risk of injury to underlying structures
Sterile gown, mask, gloves
Additional Considerations for Needle Thoracostomy
The urgency of the procedure is determined by the patient’s condition. Hypotension suggests a more advanced tension pneumothorax requiring more urgent treatment.
Relevant Anatomy for Needle Thoracostomy
Neurovascular bundles are located at the lower edge of each rib. Therefore, the needle must be placed over the upper edge of the rib to avoid damage to the neurovascular bundle.
Positioning for Needle Thoracostomy
Patient should be supine, lying on the back.
Step-by-Step Description of Needle Thoracostomy
The preferred insertion site is the 2nd intercostal space in the mid-clavicular line in the affected hemithorax. However, insertion of the needle virtually anywhere in the correct hemothorax will decompress a tension pneumothorax.
Insert the thoracostomy needle, piercing the skin over the rib below the target interspace, then directing the needle cephalad over the rib until the pleura is punctured (usually indicated by a pop and/or sudden decrease in resistance).
After doing a needle thoracostomy, insert a chest tube as soon as possible.
Aftercare for Needle Thoracostomy
Chest x-ray should be done to confirm expansion of the lung and proper placement of the chest tube.
Warnings and Common Errors for Needle Thoracostomy
Depending on the thickness of the chest wall, a longer needle may be needed.
Tips and Tricks for Needle Thoracostomy
After removing the needle, the catheter may become blocked due to kinking. Kinking is especially likely with smaller catheters, including 14 and 16 gauges. Some sources recommend using a larger 10-gauge needle and catheter (1–3).
References
1. Aho JM, Thiels CA, El Khatib MM, et al: Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter. J Trauma Acute Care Surg 80(2):272–277, 2016. doi: 10.1097/TA.0000000000000889
2. Clemency BM, Tanski CT, Rosenberg M, et al: Sufficient catheter length for pneumothorax needle decompression: A meta-analysis. Prehosp Disaster Med 30(3):249–253, 2015. doi: 10.1017/S1049023X15004653
3. Beckett A, Savage E, Pannell D, et al: Needle decompression for tension pneumothorax in Tactical Combat Casualty Care: Do catheters placed in the midaxillary line kink more often than those in the midclavicular line? J Trauma 2011 71(5 Suppl 1):S408–S412, 2011. doi: 10.1097/TA.0b013e318232e558
