Optimal Location for Needle Decompression For A Tension Pneumothorax

Optimal Location for Needle Decompression For A Tension Pneumothorax

Traditionally, needle decompression for the emergent treatment of a tension pneumothorax is the second intercostal space in the mid-clavicular line.  This remains an option for needle insertion when you are treating a tension pneumothorax.  This insertion point is just above the third rib in the mid-clavicular line.  The sternal angle (or Angle of Louie) lies at the level of the second rib.  Identify the third rib under the Angle of Louie near the sternum and follow it laterally to the mid-clavicular line to locate this insertion site.

However, recent data from the military and in cadaveric studies argue that a better insertion point for needle decompression is at the fourth or fifth intercostal space in the mid-axillary line.  The reason for this suggestion is twofold:  first, needles placed too medial within the second intercostal space may damage the subclavian artery; and second, the amount of subcutaneous tissue in the anterior axillary line is frequently less than in the mid-clavicular line based on both cadaveric studies or CT studies.

The other recommendation made by the United States Defense Health Board is that the catheters used should be at least 3.25 inches (8 cm) long in women with excessive breast tissue or obese patients.  A 2 inch (5 cm) angiocather should be sufficient in thin patients or average-sized men.

The bottom line is that needle decompression can be performed at either the midclavicular line in the second intercostal space or in the anterior axillary line in the fourth or fifth intercostal space, but make sure to use a long enough needle depending on patient habitus.




  1. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma 71(5):1099-1103, 2011. Link.

  2. Riwoe D, Poncia H: Subclavian artery laceration: a serious complication of needle decompression. Emerg Med Australasia 2011;23:651-653. Link.

  3. Harcke HT, Pearse LA, Levy AD, et al.: Chest wall thickness in military personnel: Implications for needle thoracentesis in tension pneumothorax. Milit Med 2007; 172:1260- 1263. Link.

  4. Sanchez L, Straszewski S, Fischer C, Khan A, Horn E, Saghir A, Khosa F, Camacho M. Anterior versus Lateral Needle Decompression of Tension Pneumothorax: Comparison by CT Chest Wall Measurement. Acad Emerg Med. 2011 October:18(10):1022-26. Link. – See more at: http://www.bidmc.org/Medical-Education/Departments/Emergency-Medicine/Residency/Academics-Research/Resident-Publications.aspx#sthash.qxkq6HuQ.dpuf

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