needle thoracostomy: optimal site?

TRADITIONAL SITE:
--2nd intercostal space, mid-clavicular line


ALTERNATIVE SITE:
--4th/5th intercostal space, mid-axillary line (chest tube site)


CADAVER STUDY:
--2nd intercostal, mid-clavic: needle thoracostomy successfully placed in 58% (23/40)
--5th intercostal, mid-ax: needle thoracostomy successfully placed in 100% (40/40)


CT MEASUREMENT:
--distance from skin to pleura at:

• anterior 2nd intercostal space averaged 46.3 mm on the right and 45.2 mm on the left
• midaxillary line, 4th intercostal space was 63.7 mm on the right and 62.1 mm on the left
• midaxillary line, 5th intercostal space was 53.8 mm on the right and 52.9 mm on the left

KINKING STUDY:
--significant pressure difference required to achieve free flow through the in situ angiocatheter

• 2nd intercostal space midclavicular line (7.9 ± 1.8 mm Hg)
• 5th intercostal space midaxillary line (13.1 ± 3.6 mm Hg )

BOTTOM LINE:
--2nd intercostal space, mid-clavicular line (classic site): tougher to find, but less tissue in between, less kinking
--5th intercostal space, mid-axillary line: easier to aim, but more distance (especially with rising obesity) to the pleura, risk of kinking


Submitted by S. Lee.


Reference(s): cadaver study; CT study; kinking study; picture