Complications of needle thoracostomy: A comprehensive clinical review

Abstract

Needle thoracostomy (NT) is a valuable adjunct in the management of tension pneumothorax (tPTX), a life-threatening condition encountered mainly in trauma and critical care environments. Most commonly, needle thoracostomies are used in the prehospital setting and during acute trauma resuscitation to temporize the affected individuals prior to the placement of definitive tube thoracostomy (TT). Because it is both an invasive and emergent maneuver, NT can be associated with a number of potential complications, some of which may be life-threatening. Due to relatively common use of this procedure, it is important that healthcare providers are familiar, and ready to deal with, potential complications of NT.

Keywords: Complications; emergent chest decompression; needle thoracostomy; tension pneumothorax.

Figure 1

(Left) Schematic representation of the anatomic location of the recommended anatomic location for needle thoracostomy (NT) placement in the second intercostal space, midclavicular line. Key anatomic structures in the immediate area of placement are outlined, highlighting the potential for injury if proper care is not exercised during the procedure. (Right) In addition to the second intercostal space location (top), placement of NT in the third intercostal space (midclavicular), and fourth or fifth intercostal spaces (midaxillary) has been described

Figure 2

NT may take a number of potential paths, each of which may either result in false assurance of adequate pneumothorax decompression (Left-most dashed arrow); failure to enter the thoracic cavity (second dashed arrow from left); proper catheter placement (middle, solid arrow); improper NT placement into lung parenchyma, causing lung injury and air leak (second dashed arrow from right); and improper NT advancement into an intrathoracic vascular structure, resulting in blood return (right-most dashed arrow)

Figure 3

Solid green line demonstrates the most correct (mid-hemithoracic) position of a NT; whereas, the dashed red line demonstrates a more medial (midclavicular) position that may contribute to complications due to its more “central” location

Figure 4

Trajectories commonly involved in proper and improper placements of NT; (top) proper placement of NT; (middle) improper placement into subcutaneous tissues, resulting in ineffective decompression; and (bottom) improper NT placement into the mediastinum

Figure 5

A rare demonstration of a pulmonary injury (star) that occurred during NT placement. A residual pneumothorax (left, double-sided arrow) is seen despite the placement of the NT