What is the initial emergency department (ED) care for tension pneumothorax?

Updated: Apr 28, 2020
  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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Tension pneumothorax remains a life-threatening condition diagnosed under difficult conditions, with a simple emergency procedure as treatment (ie, needle decompression). Make sure no contraindications exist for the placement of an emergency decompression catheter into the thorax. Previous thoracotomy, previous pneumonectomy, and presence of a coagulation disorder, for example, are relative contraindications, because failure to treat tension pneumothorax expectantly can result in patient death.

Under emergent circumstances, place decompression catheters in the second rib interspace in the midclavicular line. This site was confirmed by Wax and Leibowitz, who reviewed 100 thoracic CT scans by measuring the distance from the midline to the internal mammary artery and the average thickness of the tissues. [63] This procedure punctures through the skin and, possibly, through the pectoralis major muscle, external intercostals, internal intercostals, and parietal pleura. Placement in the middle third of the clavicle minimizes the risk of injury to the internal mammary artery during the emergency procedure. [63] Place the catheter just above the cephalad border of the rib, because the intercostal vessels are largest on the lower edge of the rib.

Harcke et al had similar results when they used CT analysis of deployed male military personnel to determine that, at the second right intercostal space in the midclavicular line, the mean horizontal thickness was 5.36 cm, and that an 8-cm angiocatheter would reach the pleural space in 99% of the male soldiers in this series. [64]

Unfortunately, in a 2005 study of emergency physicians, 21 of whom had completed advanced trauma and life support (ATLS) training, only 60% were able to correctly identify the second intercostal space when attempting to locate the needle thoracostomy site on a human volunteer, and all placed the thoracentesis needle medial to the midclavicular line. [62] In the same study, 8% of participants inappropriately identified the site used for needle pericardiocentesis and 4% inappropriately identified the fifth intercostal space in the anterior axillary line. [62]

A 2011 study by Sanchez et al suggested that the anterior approach is typically more successful than the lateral approach when it comes to angiocatheters, although the anterior approach is not failsafe. Further, longer angiocatheters may increase the chances of decompression, but the risk of damage to surrounding vital structures is higher. [65]

Related to the development of apparent life-threatening hemorrhage after decompression in the second intercostal space at the anterior, midclavicular line in patients with no initial evidence of hemothorax on presentation, it has been suggested that a potentially safer option is to decompress a pneumothorax in the fifth intercostal space at the anterior axillary line, similar to recommendations for chest drain insertion.

If a hemothorax is associated with the pneumothorax, additional chest tubes may be needed to assist drainage of blood and clots. If the hemopneumothorax requires insertion of a second chest tube, the second tube should be directed inferiorly and should be posterior to the apex of the diaphragm.

Another point to take note of is that a significant number of patients have a larger chest wall than can be penetrated by a catheter length of 5 cm. In particular, men undergoing treatment for tension pneumothorax are more likely to have a larger body habitus with wider chest wall, such that performing needle thoracostomy may need a catheter longer than 5 cm to reliably penetrate into the pleural space.

In one study, a catheter length of patients at an American level 1 trauma center showed that a catheter length of 5 cm would reliably penetrate the pleural space in only 75% of patients. [66] A 2008 study analyzing average chest wall thickness at the second intercostal space in the midclavicular line concluded that a 4.5-cm catheter length may not penetrate the chest wall in approximately 10-35% of trauma patients, depending on age and sex. [67]

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