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Three Part Question

Following [failed needle thoracocentesis for initially suspected tension pneumothorax without subsequent radiological evidence] does [insertion of a chest drain vs. simple observation] lead to [fewer respiratory complications]?

Clinical Scenario

A lady in her thirties is brought into the Resuscitation Room in severe respiratory distress. You initially suspect tension pneumothorax and perform needle thoracocentesis but there is no audible air leak and no clinical improvement. Chest radiograph demonstrates only hyperexpansion. The lady improves following bronchodilator therapy. The ATLS guidelines state that a chest drain is always required following needle thoracocentesis. You wonder if there is any evidence that it is necessary for this patient.

Search Strategy

MEDLINE using the OVID interface, 1966 - June 04
(exp tension pneumothorax.mp. OR exp Pneumothorax/ OR pneumothora$.mp.) AND (exp Chest Tubes/ OR pleural drainage.mp. OR chest drain.mp. OR exp Thoracostomy/ OR chest drain$.mp.) AND (thoracocentesis.mp. OR aspiration.mp.) limit to human and english language

Search Outcome

Altogether 48 papers were identified using the reported search, none of which answered the three-part question.

Comment(s)

Tension pneumothorax is not always an obvious diagnosis in the Emergency Department. False positive diagnosis is likely to lead to unnecessary thoracocentesis, which may in turn lead to iatrogenic pneumothorax (1). In addition, negative thoracocentesis, as defined by the absence of a hiss of air on insertion of the needle, is not sufficient for exclusion of tension pneumothorax (2). The ATLS guidelines suggest a chest drain should be automatically inserted after thoracocentesis (3). Although there is no evidence to justify or refute this recommendation, the risks of chest drain insertion should be balanced against the risks of iatrogenic pneumothorax in a patient who already has a degree of respiratory compromise. References: 1. Despars JA, Sassoon CS, Light RW. Chest 1994; 105(4):1147-50 2. Jones R, Hollingsworth J. Tension pneumothoraces not responding to needle thoracocentesis. Emergency Medicine Journal 2002; 19(2):176-7 3. American College of Surgeons, Committee on Trauma. Advanced trauma life support course manual. Washington DC: ACS, 1997

Clinical Bottom Line

There is no evidence that chest drainage is essential following needle thoracocentesis for respiratory distress misdiagnosed as tension pneumothorax. Local guidelines should be followed.