JOURNAL READING

RADIOLOGIC ASSESSMENT OF POTENTIAL

SITES FOR NEEDLE DECOMPRESSION OF
A TENSION PNEUMOTHORAX

PENILAIAN RADIOLOGIS TEMPAT POTENSIAL UNTUK

NEEDLE DECOMPRESSION PADA TENSION PNEUMOTHORAX

David B. Wax, MD; Andrew B. Leibowitz, MD

(Anesth Analg 2007;105:13858)

Dipresentasikan Oleh : Hajriadi Syah F. A

Pembimbing : dr. Haryo Aribowo, Sp.B-KBTKV

BACKGROUND

Recommended treatment of suspected tension

pneumothorax is immediate needle
decompression.
There are published case reports of failed needle
decompression of pneumothoraces (13).

1. Castle N, Tagg A, Owen R. Bilateral tension pneumothorax. Resuscitation 2005;65:1035

2. Jenkins C, Sudheer PS. Needle thoracocentesis fails to diagnose a large pneumothorax. Anaesthesia
2000;55:9256
3. Gilligan P, Hegarty D, Hassan TB. The point of the needle. Occult pneumothorax: a review. Emerg
Med J 2003;20:2936

BACKGROUND

Cases of life-threatening hemothorax have been

reported secondary to vascular injury from
attempted needle decompression (4).
As an alternative to the second intercostal space
at the midclavicular line, needle decompression
in the fourth or fifth intercostal spaces at the
mid- or anterior axillary lines (MAL, AAL) (the
traditional sites of tube thoracostomy) has been
proposed (2,4,5).

4. Rawlins R, Brown KM, Carr CS, Cameron CR. Life threatening haemorrhage after anterior needle
aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of
spontaneous pneumothorax. Emerg Med J 2003;20:3834
5. Barton ED. Tension pneumothorax. Curr Opin Pulm Med 1999;5:26974

BACKGROUND

The safety and efficacy of using these other sites

have not been well described
This study investigated the optimal needle length
and relative safety of three potential needle
decompression sites.

METHODS

Reviewed thoracic computed tomography (CT)

scans of 100 adult patients
The scans were selected randomly from a list of
patients who had undergone anesthesia for videoassisted thoracoscopy in the prior 12 months, and
were therefore likely to have an archived chest
CT scan.
Scans were viewed using a GE Centricity PACS
workstation (GE Healthcare,Fairfield, CT).

METHODS
List of patient who had undergone anesthesia for videoassisted thoracoscopy in the prior 12 months
Selected randomly
100 adult patients

Reviewed thoracic computed

tomography (CT) scans
viewed using a GE Centricity PACS workstation (GE
Healthcare, Fairfield, CT)
measured distances between
various anatomic sites

METHODS

Left image CT scout film of thorax

Center image thoracic CT at level of sternal angle
Right image thoracic CT at level of xiphoid process

METHODS

CT scout film of thorax:

MHL midhemithoracic line at level of sternal angle;
AAL anterior axillary line at level of xiphoid process;
MAL midaxillary line at level of xiphoid process.

METHODS

Thoracic CT at level of sternal angle

A: distance from midsternum to MHL;
B: distance from midsternum to internal mammary vessels;
C: distance from skin surface to pleura at MHL

METHODS

Thoracic CT at level of xiphoid process:

E: distance from skin surface to pleura at AAL;
F: distance from skin surface to major intrathoracic structure at AAL;
G: distance from skin surface to pleura at MAL;
H: distance from skin surface to major intrathoracic structure at MAL

METHODS

Patient age, gender, height, and weight were also

tabulated, as was the presence, or absence, of
radiologic evidence of prior sternotomy.
Exclusion criteria:
Obesity

macromastia

who had soft tissues extending beyond

the visible scan area
patients with grafted mammary vessels

METHODS

All measurements were made bilaterally and the

results tabulated for analysis.
Descriptive statistics were calculated, and x2,
Students t-test, and Spearmans rank correlation
were used as appropriate, with P < 0.05
considered statistically significant.

RESULT

100 subjects (58 male, 42 female)

Median age of 62 years (range, 2386)

Median height of 168 cm (range, 142191)

Median weight of 72 kg (range, 47118)

Median body mass index (BMI) of 26 (range, 16

41).

RESULT

13 subjects with evidence of previous sternotomy

Eight had grafted mammary vessels.

Seven subjects with incomplete data at the

axillary sites because of body habitus.

RESULT

The median distances from the midline of the

sternum at the level of the sternal angle to the
MHL and internal mammary vessels were 6.1
and 3.0 cm, respectively, with a 3.1 cm median
gap between the two (Table 1).
Median differences between the left and right
sides and between genders were 1 cm.

RESULT

RESULT

Median depth-to-pleura below the skin surface at

the MHL, MAL, and AAL sites was 3.1, 3.5, and
2.6 cm, respectively (Table 2).
Median differences between the left and right
sides and genders were 1 cm or less.

RESULT

increasing weight and increasing BMI had a

statistically significant correlation (P <0.01) with
increasing depth-to-pleura at all sites.
male (versus female) gender and increasing
height had a statistically significant correlation
(P <0.05) with decreasing depth to-pleura at the
AAL site, but not at other sites

RESULT

RESULT

There was a larger proportion of subjects with

major soft-tissue structures within both 5 and 10
cm of the needle entry site and directly adjacent
to the chest wall for bilateral MAL and AAL sites
compared with the ipsilateral MHL site
The safe distance was greatest for the MHL site
and least for the AAL site on either side.

RESULT

DISCUSSION

Suspected tension pneumothorax requires rapid

intervention
One study of 54 adults using ultrasonic
measurements in the second intercostal space at
the midclavicular line found chest wall thickness
of up to 4.4 cm in males and 5.2 cm in females,
and recommended a minimum needle length of
4.5 cm to succeed in 96% of cases (6).

6. Britten S, Palmer SH, Snow TM. Needle thoracocentesis in tension pneumothorax: insufficient
cannula length and potential failure. Injury 1996;27:3212

DISCUSSION

Another study of 111 patients using CT scans

showed chest wall thickness in the second
intercostal space at the midclavicular line of over
5 cm in nearly one-quarter of subjects (maximum,
8.2 cm), suggesting that even a 4.5 cm catheter
length would often be inadequate (7).
Writer are not aware of any published data
regarding the axillary sites.

7. Givens ML, Ayotte K, Manifold C. Needle thoracostomy: implications of computed tomography chest
wall thickness. Acad Emerg Med 2004;11:2113

DISCUSSION

This Study suggest that a needle length of 7 cm

would be adequate for nearly all patients at the
MHL site, but may be too short for the axillary
sites in some patients.

7. Givens ML, Ayotte K, Manifold C. Needle thoracostomy: implications of computed tomography chest
wall thickness. Acad Emerg Med 2004;11:2113

CONCLUSION

Needle decompression of a suspected tension

pneumothorax should be attempted in the MHL at
the level of the sternal angle using a needle at least
7 cm long inserted perpendicular to the horizontal
plane.
Half of all patients should have entry into their
pleural space accomplished in under 3.1 cm and the
remainder within 7 cm.
This approach should yield the highest success rate
and margin of safety compared to axillary sites.