Literature Review #3: Needle Thoracostomy

Do you really need to place a chest tube after a patient is "needled" in the field?

According to a recent article in the Journal of Ultrasound in Medicine, you may not need to convert that needle thoracostomy to a tube thoracostomy in every patient.1  This study was performed to assess if all patients who were needled in the field actually had a pneumothorax. 


In this prospective study, patients who received a needle thoracostomy in the field had an E-FAST exam performed upon arrival to a Level I Trauma Center during the secondary survey (57 patients over 3 years).  26% of these patients appeared to have a normal lung sliding sign on ultrasound and the thoracostomy catheter was removed.  Each patient then had a CT scan that confirmed the absence of a pneumothorax.

Although this study does seem positive, it does raise some important questions.  First of all, the length of the catheter was not noted in this article, which has been shown to affect the failure of needle thoracostomy.  Ball et al note up to a 65% failure rate in needle thoracostomies when using a 3.2 cm catheter, compared to a 4% failure rate in those performed with a 4.5 cm catheter.2  Which brings us to the second point, the size of the patient.  Were those patients in the failed needle thoracostomy group morbidly obese or highly muscular?  Although McLean et al note that a 4.5cm catheter length should be long enough to penetrate most patient's chest wall (mean anterior chest wall thickness of 2.1-2.3 cm), they note that large BMIs may exceed 4.5 cm in catheter length.3  Was the failure of the needle to penetrate into the chest cavity due to the thickness of the chest wall?  Increased tissue on the chest wall may account for both the difficulty in auscultation of breath sounds and the failure of the needle to penetrate the lung cavity.  Other factors to note in this study is the small sample size (57 patients total) and that the seven physicians who performed the scans had significant ultrasound training.  Could someone with less ultrasound experience achieve the same results?

Although there are some flaws in this study, I like it overall.  It would be interesting to see a study looking at EMS use of ultrasound in the field to determine pneumothorax.  Would it change how many people had a needle thoracostomy in the field if an ultrasound was performed before they were needled?  Would ultrasound be as reliable in the hands of less experienced sonologists?  Good research project...


1.  Blaivas, M. Inadequate Needle Thoracostomy Rate in the Prehospital Setting for Presumed Pneumothorax: an Ultrasound Study. J Ultrasound Med 2010; 29:1285-1289 PMID: 20733183
2.  Ball, C et al. Thoracic Needle Decompression for Tension Pneumothorax: Clinical Correlation with Catheter Length. Canadian Journal of Surgery. June 2010; 53:184-188 PMID: 20507791
3.  McLean, A.R., et al. Ultrasound Determination of Chest Wall Thickness: Implications for Needle Thoracostomy. Am J Emerg Med. 2010 Oct 12 [Epub ahead of print] PMID: 20947279