Sonographic evaluation of chest wall thickness in Chinese adults in Hong Kong: Should the updated (10th edition) Advance Trauma Life Support guidelines on preferred site of needle thoracocentesis in tension pneumothorax be adopted in the Asian population?

Abstract

Objective

To compare the anterior with lateral mean chest wall thickness measured by bedside ultrasound in Chinese adults in order to suggest a preferred site for needle decompression in tension pneumothorax.

Study design

This was an observational cross-sectional study conducted in a regional hospital over three months. Subjects were recruited by convenience sampling. Chest wall thickness at the second intercostal space, mid clavicular line, fifth intercostal space, anterior axillary line and fifth intercostal space and mid axillary line was measured using ultrasound on both sides. Range, mean values and confidence intervals were calculated.

Results

One-hundred and fourteen subjects were recruited. The mean anterior chest wall thickness was 2.62 cm (at second intercostal space, mid-clavicular line) and mean lateral chest wall was 2.68 cm (at fifth intercostal space, anterior axillary line) and 2.87 cm (at fifth intercostal space and mid-axillary line) respectively. Chest wall thickness at fifth intercostal space and mid-axillary line was significantly greater than second intercostal space, mid-clavicular line (p < 0.01). Chest wall thickness was greater than 5 cm in 3.5% of the study population.

Conclusion

There is a need for population-based guidelines. We recommend needle decompression at the second intercostal space, mid-clavicular line with a 50-mm angiocath for Chinese patients with tension pneumothorax. A lateral approach at the fifth intercostal space, anterior axillary line may be considered as an alternative in case of failure. Prehospital point-of-care ultrasound may be a useful adjunct in managing such patients.

Keywords

Tension pneumothorax thoracocentesis trauma

Get full access to this article

View all access options for this article.

References

Kaserer

Stein

Simmen

, et al. Failure rate of prehospital chest decompression after severe thoracic trauma. Am J Emerg Med 2017; 35: 469–474.

Laan

Thiels

, et al. Chest wall thickness and decompression failure: a systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury 2016; 47: 797–804.

Rottenstreich

Fay

Gendler

, et al. Needle thoracotomy in trauma. Military Med 2015; 180: 1211–1213.

Inaba

Branco

Eckstein

, et al. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma 2011; 71: 1099–1103.

Ozen

Akoglu

Ozdemirel

, et al. Determination of the chest wall thicknesses and needle thoracostomy success rates at second and fifth intercostal spaces: a cadaver-based study. Am J Emerg Med 2016; 34: 2310–2314.

Akoglu

Evman

, et al. Determination of the appropriate catheter length and place for needle thoracostomy by using computed tomography scans of pneumothorax patients. Injury 2013; 44: 1177–1182.

Sanchez

Straszewski

Saghir

, et al. Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement. Acad Emerg Med 2011; 18: 1022–1026.

Yamagiwa

Morita

Yamamoto

, et al. Determination of the appropriate catheter length for needle thoracostomy by using computed tomography scans of trauma patients in Japan. Injury 2012; 43: 42–45.

Goh

Teo

. Decompression of tension pneumothoraces in Asian trauma patients: greater success with lateral approach and longer catheter lengths based on computed tomography chest wall measurements. Eur J Trauma Emerg Surg 2017; 44: 767–771.

10.

McLean

Richards

Crandall

, et al. Ultrasound determination of chest wall thickness: implications for needle thoracostomy. Am J Emerg Med 2011; 29: 1173–1177.

11.

Britten

Palmer

Snow

. Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure. Injury 1996; 27: 321–322. (abstract only).

12.

Lamblin

Turc

Bylicki

, et al.

Measure of chest wall thickness in French solders: which technique to use for needle decompression of tension pneumothorax at the front?

Military Med 2014; 179: 783–783.

13.

Centre for Health Protection, Department of Health – Body Mass Index (BMI) Distribution, https://www.chp.gov.hk/en/statistics/data/10/280/427.html (accessed 8 December 2019).

14.

McPherson

Feigin

Bellamy

. Prevalence of tension pneumothorax in fatally wounded combat casualties. J Trauma 2006; 60: 573–578.

15.

Davis

Pettit

Rom

, et al. The safety and efficacy of prehospital needle and tube thoracostomy by aeromedical personnel. Prehospital Emerg Care 2005; 9: 191–197.

16.

Barton

Epperson

Hoyt

, et al. Prehospital needle aspiration and tube thoracostomy in trauma victims: a six-year experience with aeromedical crews. J Emerg Med 1995; 13: 155–163.

17.

World Health Organization 2017. Source: Global Health Observatory, http://www.who.int/gho/en/ (Published 2017, accessed 8 December 2019).

18.

Centre for Health Protection, Department of Health – Body Mass Index (BMI) Distribution, https://www.chp.gov.hk/en/statistics/data/10/280/427.html (accessed 8 December 2019).

19.

Beckett

Savage

Pannell

, et al.

Needle decompression for tension pneumothorax in tactical combat casualty care: do catheters placed in the midaxillary line kink more often than those in the midclavicular line?

J Trauma 2011; 71: S408–S412.

20.

Zengerink

Brink

Laupland

, et al.

Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle?

J Trauma 2008; 64: 11–14.

21.

Wax

Leibowitz

. Radiologic assessment of potential sites for needle decompression of a tension pneumothorax. Anesth Analg 2007; 105: 1385–1388.

22.

Netto

Schulman

Rizoli

, et al.

Are needle decompressions for tension pneumothoraces being performed appropriately for appropriate indications?

Am J Emerg Med 2008; 26: 597–602.

23.

Ball

Wyrzykowski

Kirkpatrick

, et al. Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Can J Surg 2010; 53: 184–188.

24.

Aho

Thiels

El Khatib

, et al. Needle thoracostomy: clinical effectiveness is improved using a longer angiocatheter. J Trauma Acute Care Surg 2016; 80: 272–277.

25.

Rawlins

Brown

Carr

, et al. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J 2003; 20: 383–384.

26.

Butler

Best

Weaver

, et al. Pulmonary artery injury and cardiac tamponade after needle decompression of a suspected tension pneumothorax. J Trauma 2003; 54: 610–611.

27.

Connor

Bleetman

Duddy

. Safety standards for stab-resistant body armour: a computer tomographic assessment of organ to skin distances. Injury 1998; 29: 297–299.

28.

Tien

Jung

Rizoli

, et al. An evaluation of tactical combat casualty care interventions in a combat environment. J Am Coll Surg 2008; 207: 174–178.

29.

Blaivas

Lyon

Duggal

. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med 2005; 12: 844–849.

30.

Kirkpatrick

Sirois

Laupland

, et al. Hand-held thoracic sonography for detecting posttraumatic pneumothoraces: the extended focused assessment with sonography for trauma (EFAST). J Trauma 2004; 57: 288–295.

31.

Walcher

Weinlich

Conrad

, et al. Prehospital ultrasound imaging improves management of abdominal trauma. Br J Surg 2006; 93: 238–242.

32.

Nelson

Sanghvi

. Out of hospital point of care ultrasound: current use models and future directions. Eur J Trauma Emerg Surg 2016; 42: 139–50.

33.

Ketelaars

Hoogerwerf

Scheffer

. Prehospital chest ultrasound by a Dutch Helicopter Emergency Medical Service. Ultrasound in emergency medicine. J Emerg Med 2013; 44: 811–817.