Clinical Practice Guidelines

Needle Thoracocentesis

  • See also:  Primary Spontaneous Pneumothorax
    Chest Drain (Intercostal Catheter) Insertion 

    Notes

    Needle aspiration (thoracocentesis) is now an established initial intervention in selected patients with primary spontaneous pneumothorax (see  Primary Spontaneous Pneumothorax)  

    • It is the only acceptable immediate intervention in cases of tension pneumothorax 
      • Tension pneumothorax is a clinical diagnosis. There is a 10 - 20 % chance of causing a pneumothorax if thoracocentesis is attempted and the child does not have a pneumothorax.  This procedure must be followed up by chest x-ray, and will require a chest drain if the patient is ventilated.

    Indications:

    • Primary spontaneous pneumothorax
    • Tension pneumothorax

    Relative contraindications:

    Thoracocentesis should be only be considered in consultation with a senior emergency physician in the following:

    • Spontaneous pneumothorax in patients with underlying lung disease
    • Traumatic pneumothorax without tension

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    Equipment

    • Dressing pack
    • Aspiration device
    • Large bore cannula (12 or 14 gauge)
    • Central venous catheter (CVC) or Pigtail catheter are alternatives
    • 20ml or 50ml syringe
    • 3 way tap
    • Antiseptic solution
    • 1% lignocaine ampoule
    • Sleek and Tegaderm x 2

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    Analgesia, Anaesthesia, Sedation

    Analgesia and local anaesthesia are mandatory except with tension pneumothorax, which is immediately life-threatening.

    • Use local anaesthetic or EMLA/ANGEL
    • Consider oral or parenteral analgesia pre- and post-procedure

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    Procedure

    • Place patient on continuous cardiac monitoring and pulse oximetry
    • Patient position
    • Place trauma patient in a head-up, supine position
    • All other patients should be placed in 45-degree, sitting position 
    • Palpate landmark (the upper border of the 3rd rib in the midclavicular line) and antiseptically prepare the area
    • Attach a 5ml syringe to the catheter device
    • Puncture the skin at the level of above landmark 
    • Carefully insert the needle at a slightly downwards angle into the pleural space while aspirating the syringe
    • In tension pneumothorax, often you will hear a pop or feel a change of resistance
    • Withdraw the needle while gently advancing the cannula downwards into position
    • Secure cannula/CVC with tape/tegaderm
    • Attach 3 way tap and 50ml syringe
    • Drain until no further drainage or to a maximum of 30ml/kg (max 2.5l)

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    Post-Procedure Care

    Reassess ABCs