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Three Part Question

In [patients with pneumothorax requiring immediate decompression] is [the lateral approach] better than [anterior approach] in terms of [effectiveness and safety]?

Clinical Scenario

A 55-year-old patient with high BMI and known COPD is brought to the Emergency Department by paramedics, complaining of sudden onset of severe difficulty in breathing. The patient has decreased air entry on the right side, the trachea is deviated to left and hyper-resonance is noted on the right side. A clinical diagnosis of tension pneumothorax is made and immediate needle decompression is indicated. You wonder which approach is better for immediate needle decompression - the anterior approach (2nd intercostal space, mid-clavicular line) or the lateral approach (5th intercostal space, anterior or mid-axillary line).

Search Strategy

MEDLINE 1950 to January 2012 via NHS Evidence web interface.
(pneumothor* AND (thoraco* OR decompress*) AND needle* AND (site* OR position* OR location*)).af

Search Outcome

39 papers identified. 5 papers were relevant to the search question. 1 was a cadaveric study, 2 were radiological studies, 1 was an observational study.

The BTS Guideline on Management of spontaneous pneumothorax (2010) was also reviewed.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Inaba et al November 2011 USA	A random selection of 20 adult fresh cadavers 14 males and 6 females were included in this study.	A Cadaver based study.	Success rate of 5th ICS vs 2nd ICS	100%, 40 out of 40 needles placed in the 5th ICS vs 57.5%,(23 of 40) of the needles placed in the 2nd intercostal space entered the chest cavity (p < 0.001).	Cadaver based study and result are not validated for live patients.
			Chest wall thickness difference.	On average, the chest wall was 1 cm thinner at 5th ICS, 3.5cm +_ 0.9cm at 5th ICS compared to 4.5cm +_ 1.1cm at 2nd ICS (P < 0.001)
			Success rate by gender at 2nd ICS	Males 75.0% as compared to 16.7% in females (P < 0.001)
E P Ferrie, N Collum, S McGovern 22 December 2004 Northern Ireland, UK	A cohort of 25 emergency physicians was studied, 21 (84%) of which were ATLS certified.	An observational study.	Theoretical knowledge of site of NT.	22 out of 25 (88%, with 95% confidence interval (CI) 69 to 95%) of the participants named the landmark as 2nd ICS midclavicular line..	Small sample size, from which it is difficult to draw statistical significance. A range of volunteers may have given more useful results.
			Correct identification of site of NT.	15 out of 25 (60%, with 95% CI 39 to 79%) were able to correctly identify the site of NT at 2nd ICS midclavicular line on the human volunteer.
MacDuff et al, 2010 UK	Patients with Spontaneous pneumothorax	British Thoracic Society pleural disease guideline 2010.	Failure rate of anterior needle decompression.	Fails in up to one third of patients due to chest wall thickness > 5cm ,chest wall may be less deep in the fourth or fifth interspace, and this could provide an alternative site for decompression.
Sanchez et al October 2011 United States of America	Emergency Department patients who underwent computed tomography of the chest as part of their evaluation for blunt trauma.	A convenience sample of 159 patients was formed by reviewing consecutive scans of eligible patients. Six measurements from the skin surface to the pleural surface were made for each patient: anterior second intercostal space, lateral fourth intercostal space, and lateral fifth intercostal space on the left and right sides.	Distance from skin to pleura at the anterior second intercostal space	46.3 mm (R), 45.2 mm (L)	(1) US-based study. UK populations may have different chest wall thickness. (2) This is a descriptive study of chest wall measurements only - all the study participants did not have needle decompression.
			Distance from skin to pleura at the midaxillary line in the fourth intercostal space	63.7 mm (R), 62.1 mm (L)
			Distance from skin to pleura at the fifth intercostal space	53.8 mm (R), 52.9 mm (L)
Wax DB, Leibowitz AB November 2007 United States of America	Thoracic computed tomography scans of 100 adults.	The investigators measured the distance from skin surface to pleura and to intrathoracic structures at the level of the sternal angle at the midhemithoracic line (MHL), and at the level of the xiphoid process at the anterior axillary and midaxillary lines, as well as the distance from the sternal midline to internal mammary vessels.	Median distances from the midline to the MHL	6.1cm	(1) Radiological descriptive study only - no interventions performed (2) US population studied - may not be generalisable to UK.
			Median depth to pleura at MHL	3.1 (1.4-6.9) cm
			Medial depth to pleura at midaxillary lines	3.5 (1.7-9.3+) cm
			Median depth to pleura at anterior axillary line	2.6 (1.0-7.7+) cm

Comment(s)

There is conflicting evidence regarding the optimal site for emergency needle decompression of a pneumothorax. The Advanced Trauma Life Support (ATLS) course has traditionally taught that the second intercostal space, mid-clavicular line is the optimal location. However, there is a large body of evidence documenting damage to chest structures such as the internal mammary and subclavian vessels from this approach. Also, some patients (especially females and obese patients) may have a chest wall thickness greater than the length of the 14G catheters that ATLS recommends for this procedure. Increasingly, interest has focused on the lateral approach for needle decompression, either at the mid-axillary line or at the anterior axillary line, in the fifth intercostal space. There is evidence from computed-tomography and cadaveric studies that the chest wall thickness at these sites may be comparable to the site of anterior approach. The sites for the lateral approach may also be safer as there are fewer vulnerable chest structures associated with them. The lateral approach may also permit concurrent chest compressions in patients with cardiac arrest due to tension pneumothorax.

Clinical Bottom Line

In patients with pneumothorax requiring immediate needle decompression, the lateral approach should also be considered as an alternative to the traditional anterior approach.

References

1. Inaba K, Branco B C, Eckstein M et al. Optimal Positioning for Emergent Needle Thoracostomy: A Cadaver-Based Study The Journal of TRAUMA® Injury, Infection, and Critical Care Volume 71, Number 5, November 2011, Number 1099–1103)
2. E P Ferrie, N Collum and S McGovern The right place in the right space? Awareness of site for needle thoracocentesis. Emergency Medicine Journal 2005 22: 788-789
3. R Rawlins et al Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax Emergency Medicine Journal 2003;20:383–384
4. MacDuff A, Arnold, A, Harvey J, on behalf of the BTS Pleural Disease Guideline Group Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010 group.bmj.com 2010;65(Suppl 2):ii18eii31. doi:10.1136/thx.2010.136986
5. Sanchez LD, Straszewski S, Saghir A, et al. Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement Academic Emergency Medicine October 2011, 18(10), 1022-6
6. Wax DB, Leibowitz AB Radiologic assessment of potential sites for needle decompression of a tension pneumothorax Anesthesia & Analgesia November 2007, 105(5), 1385-8