Needle Thoracostomy: How to do it? [Complete Guide]

Needle Thoracostomy

Needle thoracostomy refers to the process of inserting needles through the pleural space to relieve pneumothorax tension.

Needle thoracostomy is a life-saving and potentially life-saving procedure that can be performed if tube thoracostomy is not completed promptly.


A tension pneumothorax (TP) is a life-threatening condition where the air is trapped in the pleural cavity surrounding the lung. It can happen either due to injury into the chest cavity or a sudden air leak from the lung within the lung.

The pleural cavity causes dissociation of lung tissue from chest walls, disrupting breathing patterns.

Pneumothorax can be small, but it is not converted to tension; however, when there is an increasing and significant volume of air trapped within the pleural cavity, rising air pressure makes the lung shrink and collapse and result in breathing difficulties.

The pressure pushes the mediastinum (including the heart and major vessels) away from its original position, which causes it to be inaccessible to blood returning to the heart and reducing the heart’s output.

Tension pneumothoraces can cause chest pain, severe breathlessness, and respiratory failure, as well as hypoxia, tachycardia, as well as hypotension. They must be treated immediately when a patient is in extremis.

Tension pneumothoraces are managed through procedures that permit the removal of air trapped by inserting an airway tube into the chest. The materials required for the placement of a chest tube are not readily available outside the hospital setting.

It is necessary to take temporary measures in the case of patients who are deteriorating before their hospitalization or when chest tube materials are being collected. Urgent needle torsionomy (also known as “needle decompression”) is carried out in these cases.

It is simply the procedure of inserting a large-bore needle or cannula into the chest cavity and then into the pleural cavity to allow air trapped in the space to escape from the pleural cavity.

If a catheter or a cannula is not readily available, the procedure could be accomplished using a long needle with a large-bore coupled to the syringe. Air can be sucked out of the pleural cavity by using the needle.

A needle made of metal cannot stay in the pleural space since the sharp edge could cause more damage. Therefore it should get removed from your chest after the air has been aspirated.

The indications for Needle Thoracostomy

  • Tension pneumothorax must be decompressed before Needle thoracostomy can be performed.

Indications against Needle Thoracostomy

  • None

There aren’t any contraindications as this procedure is carried out in response to an immediate danger to life that overrides other considerations.

The complications of Needle Thoracostomy

  • Diaphragmatic or pulmonary laceration
  • Intercostal neuralgia resulting from an injury to the neurovascular bundle beneath the (rib)
  • Bleeding
  • Infection
  • Pneumothorax (if the procedure was performed due to an incorrectly believed pneumothorax)
  • Rarely Perforation of other structures in the abdomen or chest.

Equipment to assist with Needle Thoracostomy

  • A 14 gauge needle or 16 gauge (an over-the-needle catheter works best) needles with 8 cm are more effective than 5-cm needles; however, they can increase the chance of injury to the structures beneath.
  • Sterile gown, mask, gloves
  • A cleansing solution like the chlorhexidine solution of 2%

Additional Ideas for Needle Thoracostomy

  • The condition of the patient determines the importance of the procedure. Hypotension indicates a more severe tension pneumothorax that requires more urgent treatment.

Setting up for Needle Thoracostomy

  • The patient ought to be in a prone position, lying back on their back.

Relevant Anatomy of Needle Thoracostomy

  • The neurovascular bundles are situated in the lower part of every rib. Therefore, the needle should be placed on one of the edges to prevent damage to nerve bundles.

Step-by-Step Description of the procedure

  • The most preferred site for insertion is the second intercostal space within the mid-clavicular line within the affected hemothorax. However, placing the needle almost anywhere within the proper hemothorax can relieve a pneumothorax of tension.
  • If you have the time, it is possible to prepare the area and around the place of insertion with an antiseptic solution like chlorhexidine.
  • It is not often possible to inject local anesthesia; however, if you do an opportunity, inject 1% of lidocaine through the skin subcutaneous tissue, the rib peristemum (of the rib just below the insertion site), and the parietal pleura.
    Inject a significant dose of local anesthetic in the extremely sensitive periosteum as well as the parietal pleura. Aspirate using the syringe before injecting lidocaine to avoid injecting into blood vessels.
    It’s possible to confirm the correct placement by returning air to the anesthetic syringe upon entering the pleural space.
  • Inject the needle into the thoracostomy and puncture the skin above the rib below the targeted interspace. Then, guide the needle cephalad along the rib until the pleura has been punctured (usually indicated by a popping or a sudden drop in the resistance).
  • After performing insertion of a needle, place the lung tube immediately if it is possible.

The following care for Needle Thoracostomy

  • The chest x-ray is recommended to verify the lung expansion and the correct placement for the chest tube.

Warns, Common Errors Needle Thoracostomy

  • Based on the size of your chest, a longer needle could be required.

Tips and Tricks to Needle Thoracostomy

  • When the needle is removed, the catheter could be blocked due to Kinking. Kinking is more likely to occur for catheters with smaller diameters like 14 or 16 gauges. Specific sources suggest the use of a needle with a 10-gauge gauge and catheter.

Needle Thoracotomy during Trauma


Tension pneumothorax is the leading cause of death in trauma patients. Needle thoracostomy (NT) is currently the most commonly used first-line treatment, but it hasn’t been validated well.

In the review, we’ve reviewed the evidence supporting NT procedure, re-examined guidelines of the Advanced Trauma Life Support organization, and analyzed the safest and most effective method of NT.

The evidence available to help the application of NT is not sufficient. If used, it is recommended to place it within the 2nd intercostal space, near the midclavicular line, with the length of the catheter to be at a minimum of 4.5 cm.

Other options should be considered to improve the prehospital treatment of tension pneumothorax.


Tension pneumothorax can be a life-threatening disease where air quickly collects in the pleural cavity, which increases the pressure in the intrapleural space and impairs lung function.

The possibility of death is heightened due to the collapse of the cardiovascular system due to an increase in intrathoracic pressure and diminished return of venous blood. The quick relief of intrapleural pressure could save a life.

Needle thoracostomy (TT) is the most effective treatment for tension pneumothorax.1 The time-tested procedure is performed at the hospital setting in prehospital settings, the combat field, or the emergency room.

However, in certain situations, TT might not be suitable, for instance, in the prehospital setting, especially in cases where the transportation time is limited, and there isn’t enough time to finish the procedure.

Furthermore, executing an extensive and lengthy process in a hostile environment or a fire situation might be unattainable. Needle Thoracotomy (NT) was initially thought of as a quick and quick method of chest decompression.

It could also work as a bridge between TT. If it is successful, it could be a lifesaving procedure that relieves the high intrapleural pressure. NT was never intended to be an effective treatment for pneumothorax.

Following the most recent version of Advanced Trauma Life Support (ATLS), In cases of tension pneumothorax, NT is suggested during the initial examination.

The needle should be placed in the 2nd intercostal space (ICS2) within the middle clavicular line (MCL) located ipsilaterally of the pneumothorax. The needle suggested being used 14 gauge in diameter and 4.5-millimeter length.

In the recent decade, there’s been a lot of controversy regarding the effectiveness of NT, its ideal size, and its recommended needle characteristics.

We review the current evidence and suggestions regarding NT, focusing on patient outcomes, the technical aspects of catheter placement, and the possible hazards and complications that could arise due to the order.


The effectiveness of prehospital NT in the treatment of tension pneumothorax has been tested using animal models and human studies.

Martin et al. created a porcine model of tension pneumothorax, which had simultaneous 77% and 54 percent decrease of cardiac output as well as systolic blood flow, respectively. Then, they used 14G needles for NT.

The results were disappointing. Most NT was initially patentable, but 26% of them showed mechanical failure within five minutes after placement.

Another 32 percent of NT, however, even though patentable within 5 minutes, failed to relieve intrapleural pressure with a percent fail rate. This study found that TT did a great job in alleviating tension pneumothorax in 100 percent of instances.

In the 2nd phase of their research, they developed a model of tension pneumothorax that results in no electrical activity. They observed a failure rate of 64% during the restoration of perfusion with the NT technique compared to 0% with TT.

Furthermore, the time taken to restore the perfusion appeared to be significantly less for the arm with TT than the NT arm.

The effectiveness of NT in humans is not conclusive. Eckstein and colleagues conducted a prospective case study on 624 urban trauma victims.

Of 108 patients who received NT, just 77% and 5% experienced clinical and vital signs improvements, respectively. Casting doubt on the effectiveness of NT.

But, other studies have found different findings. Davis and colleagues’ most comprehensive retrospective study was conducted over seven years in a combat-zone setting.

Of the 89 NT implemented, 60% experienced an improvement in their overall clinical condition, and 32% showed improved vital indicators. The study did not test the effectiveness of NT with TTT.

The subsequent most extended study is a six-year retrospective review of trauma patients treated with TT or NT administered out in the field by medical personnel from the air.

The study found that, among the 207 victims of trauma, there were no differences among NT and TT administered in a battle zone in terms of improvements in the clinical condition as well as mortality rates overall.

However, 38% of patients who received TT experienced a failed initial attempt to undergo NT.

The inability of NT to alleviate a tension pneumothorax with the 14G needle by ATLS guidelines is due to two primary causes:

The first is catheter placement, i.e., If the catheter is not long enough or is inserted at an improper angle, the needle might not be able to reach the pleural cavity.

The following discussion showed remarkably high success rates with NT when longer catheter lengths were utilized.

Another reason could be mechanical failure, i.e., the catheter may become mechanically kinked, or become occluded through a blood clot, or the lung tissue is expanding.


Tension pneumothorax is among the leading causes of death among trauma patients. The first treatment recommended is temporary decompression of the needle and then the ideal placement of the chest tube.

There is no evidence-based research to suggest using NT for the treatment of tension pneumothorax.

None of the prospective randomized human studies have been published to date. Furthermore, every study that assessed the efficacy of NT employed various definitions for “clinical enhancement.”

Controlled, prospective research that follows accepted guidelines for improvement in clinical quality is required to assess the efficacy of NT for the treatment of tension pneumothorax.

When considering the ideal place to place the NT placement, most of the studies have a high rate of failure when a needleless than 4.5 cm length was utilized for the ICS2 at MCL.

It could be due to the length of the catheter being inadequate and suggest the use of a larger catheter, like that employed in the IDF.

The most delicate part of the wall of your chest was discovered to be ICS5 in the AAL. However, needle insertion inside ICS5 leads to more occlusions and accidental vascular and organ damage.

The evidence supporting using NT to treat tension pneumothorax appears insufficient. If used, NT should be applied in ICS2 in the MCL with a length of at a minimum of 4.5 cm.

Large controlled trials randomized to a large number of participants are required to determine the most effective location of a catheter to use NT and the most appropriate specifications for the catheter as a whole.

Future research should concentrate on alternatives to the management of tension pneumothorax.

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