Needle Thoracostomy vs Chest Tube

needle thoracostomy vs chest tube

Tension pneumothorax (TP) is a life-threatening condition that requires immediate decompression. This is because patients may experience sudden deterioration at a later stage. As it occurs in 1% to 3% of patients in prehospital, major trauma, and intensive care units, knowledge of emergency healthcare is essential.

Experts at Hospital Procedures Consultants will give you a rundown on the best approach for needle thoracostomy vs chest tube in this article.

A Look at the Types of Pneumothorax

Pneumothorax can be spontaneous or traumatic. Spontaneous pneumothorax fall under 2 classifications:

Primary Spontaneous Pneumothorax

Primary spontaneous pneumothorax is an abnormal condition with no known underlying condition.

The risk is higher for patients under 45 years old; patients with homocystinuria, Marfan’s syndrome, mitral valve prolapse; and patients who are male, thin and/or smoke. If the chest wall-lung margin (CW-L) is lower than 2 centimeters, high-flow oxygen should be administered under close observation. This conservative treatment plan has a lower risk of serious adverse events.

Secondary Spontaneous Pneumothorax

Secondary spontaneous pneumothorax occurs in patients with underlying lung disease, lung infections, catamenial pneumothorax, and cancer (sarcoma or lung cancer).

Treatment with a small bore chest tube is recommended. It has a recurrent rate as high as 40% to 56% after the first episode. However, it can increase the mortality rate by 3.5 times with each occurrence of chronic obstructive pulmonary disease (COPD). Hence, the patient must be hospitalized in case a video-assisted thoracic surgery (VATS) for bullectomy and pleurodesis becomes necessary.

First Step for Needle Thoracostomy vs Chest Tube

Needle decompression (ND) needs to be performed first to decompress trapped and expanding pleural air. It is indicated for patients with a tension pneumothorax that can be manifested clinically with distended neck veins, increased agitation, hypotension, progressively worsening dyspnea/cyanosis, and tracheal/mediastinal deviations contralaterally.

Once the patient is stabilized, the insertion of a chest tube—a process known as tube thoracostomy—should quickly follow. Tube thoracostomy draws air from the pleural cavity and creates negative intrathoracic pressure in the chest. This enables the lung’s re-expansion and the restoration of cardiac function.

While common, the procedure is not foolproof. Thoracostomy fails to completely evacuate the hemothorax in around 5% of cases. The condition is called retained hemothorax (RH). It can lead to complications like empyema, fibrothorax, and pneumonia. If performed on ventilated patients, it poses a larger risk with mortalities reaching 91%.

Thus, familiarization with the process is critical. 

Pre-Procedure Management 

Here’s a look at when the procedure is advisable and inadvisable:

Indications

This procedure is considered suitable under these conditions:

  • Chylothorax
  • Empyema or complicated parapneumonic effusions
  • Hemothorax
  • Hydrothorax after cardiothoracic surgery 
  • Pneumothorax (symptomatic or clinical instability, large asymptomatic pneumothorax)
  • Recurrent pleural effusions
  • To aid chemical pleurodesis in malignant effusions

Contraindications

Here are some scenarios where the procedure can be harmful to the patient:

  • Coagulopathy (relative contraindication)
  • Known multiple pleural adhesions
  • Known or suspected mesothelioma
  • Overlying skin infection
  • Pleural effusions secondary to pleural tuberculosis
  • Thrombocytopenia (less than 20,000 platelets)
  • Hepatic hydrothorax

It is also contraindicated in patients with hepatic hydrothorax. Research suggests it can lead to higher 30-day mortality compared to thoracentesis.

Research-Backed Tips for Successful Tension Pneumothorax Management 

Here are some tips that can help you successfully treat and manage TP with needle thoracostomy vs chest tube:

Positioning of the Patient 

The patient should be semi-recumbent at a 45-degree angle. An ipsilateral arm should be secured over the head to lower the incidence of clinically diagnosed VAP.

Use Ultrasound for Diagnosis 

Pathologies like hemorrhagic shock with concomitant rib fracture have similar symptoms to TP. It’s important to conduct a bedside ultrasound whenever possible as it can detect pneumothorax. Ultrasound monitoring offers 94% sensitivity and 100% specificity which is useful for unstable patients. 

Use the Proper Equipment 

Research suggests that the inadequate management of TP might stem from insufficient angiocatheter length and its incorrect positioning or obstruction due to twisting or the formation of blood clots. There is a hypothetical failure rate of 2.5% for 1.75-inch IV catheters and 0.8% for a standard 2-inch angiocatheter at ICS2-MCL.

The catheter length should be a minimum of 6.44 centimeters. A meta-analysis of 13 studies showed that 95% of patients had their pleural spaces penetrated at the site where the needle was decompressed.

Focus on the Insertion Site and Placement

The second intercostal space in the midclavicular line (ICS2-MCL) and the 4th/5th intercostal space in the mid axillary line (ICS-AAL) were recommended as preferred locations for needle decompression. By following this guideline, clinicians can prevent injuring the surrounding neurovascular structure.

The thickness of the chest wall influences the likelihood that the needle will pierce the thoracic cavity. Since it is thicker in ICS 4/5-MAL in overweight and obese patients, the chances of the ND’s success is better in ICS2-MCL.

Ultrasound can also be used to accurately locate the correct intercostal space for thoracostomy incision and to guide chest tube placement. 

Select the Correct Chest Tube Size 

Small bore chest tubes (less than 20 Fr) are associated with fewer complications (9.5% vs. 27.4%), fewer chest tube days (4.9 vs. 8.3 days), and shorter hospital LOS (6.9 vs. 11.8 days) compared to large bore chest tubes (≥20 Fr).

They also had a higher success rate at 85.7% vs. 56.5%.

Use small-bore chest tubes for malignant effusion drainage, pleural effusion drainage (infected or non-infected), pneumothorax evacuation, and stable traumatic hemothorax or pneumothorax. However, for more viscous processes like TP and unstable traumatic hemothorax, it’s best to employ a large-bore tube.

Administer Prophylactic Antibiotics

Prophylactic antibiotics can reduce the incidence of empyema and its associated morbidity with emergency tube thoracostomies. However, there is a risk that the excessive use of antimicrobials could lead to the occurrence of resistant organisms. 

Are There Any Adjuncts?

Studies suggest simple thoracostomy, also known as finger thoracostomy, could be a viable adjunct to tube thoracostomy. It can be performed safely and efficiently by properly trained paramedics in ground EMS. 

It can reduce the risks linked with incorrect needle placements and provides a 7% chance of survival until hospital discharge with normal neurological function.

The pigtail catheter is recommended in hemodynamically stable patients.

Improve Your Skills With HPC

Although the occurrence of complications necessitating intervention following prehospital NT placement in urban, rural, and wilderness environments has been low, studies suggest that 19% of these procedures have not been medically justified.

To ensure the tube is placed only where necessary, simulation and cadaver-based training should be considered to improve outcomes. 

Hospital Procedures Consultants offers a needle compression course that covers the mid-clavicular line or the mid-axillary line insertion and a comprehensive tube thoracostomy course. They teach participants indications, contraindications, and more. 

For more articles like these or to learn more about our courses, please explore our website.

Resources:

Osterman, J. Kay, A. B. Morris, D. S. Evertson, S. Brunt, T. Majercik, S. Prehospital decompression of tension pneumothorax: Have we moved the needle? Am J Surg. 2022 Dec;224(6):1460-1463. Doi: 10.1016/j.amjsurg.2022.09.014. Epub 2022 Sep 24.
Azizi, N. Ter Avest, E. Hoek, A. E. Admiraal-van de Pas, Y. Buizert, P. J. Peijs, D. R. Berg, I. Rosendaal, A. V. Boeije, T. Rietveld, V. Olgers, T. Ter Maaten, J. C. Optimal anatomical location for needle chest decompression for tension pneumothorax: A multicenter prospective cohort study Injury. 2020 Oct 17:S0020-1383(20)30888-3. doi: 10.1016/j.injury.2020.10.068. Online ahead of print
Neeki, M. M. Cheung, C. Dong, F. Pham, N. Shafer, D. Neeki, A. Hajjafar, K. Borger, R. Woodward, B. Tran, L. Emergent needle thoracostomy in prehospital trauma patients: a review of procedural execution through computed tomography scans Trauma Surg Acute Care Open. 2021 Aug 27;6(1):e000752. doi: 10.1136/tsaco-2021-000752. eCollection 2021.
Anderson, D. Chen, S. A. Godoy, L. A. Brown, L. M. Cooke, D. T. Comprehensive Review of Chest Tube Management: A Review. JAMA Surg. 2022 Mar 1;157(3):269-274. doi: 10.1001/jamasurg.2021.7050.

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