Thoracocentesis

  • See also:

    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 considered after consultation in the following;

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

    Equipment 

    • Dressing pack
    • Antiseptic solution
    • 1% lignocaine ampoule
    • Emla/Angel gel
    • Large bore cannula (12, 14 or 16 gauge)
      • Central venous catheter (CVC) or pigtail catheter are alternatives
    • 5ml syringe
    • 3 way tap
    • 20ml or 50ml syringe
    • Tegaderm X2 / tape

    Analgesia, Anaesthesia, Sedation  

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

    • Consider procedural sedation (see Analgesia and Sedation guideline)
      • Nitrous oxide should not be used as it may enter the pleural space by diffusion and rapidly increase the volume of the pneumothorax
    • Use local anaesthesia (and EMLA/Angel gel if possible)
    • Consider oral or parenteral analgesia pre- and post-procedure.
      • Placement and presence of an intercostal catheter device is painful.  

    Procedure  

    • Place patient on continuous cardiac monitoring and pulse oximetry
    • Patient position
      • Place trauma patient in head-up, supine position
      • All other patients should be placed in 45-degree, sitting position
    • Palpate landmark (2nd intercostal space, at the upper border of the 3rd rib in the midclavicular line) and antiseptically prepare the area
      • Alternative landmark is the 4th or 5th intercostal space just anterior to mid-axillary line
    • Attach a 5ml syringe to the catheter device (cannula or CVC or pigtail)
    • Insert the cannula vertically into the chest wall, just above the rib below, aspirating all the time2
    • In tension pneumothorax, often you will hear a pop or feel a change in resistance
    • Withdraw the needle while gently advancing the cannula downwards into position
    • Secure the cannula with tape/tegaderm
    • Attach 3 way tap and 20ml/50ml syringe
    • Drain until no further drainage to a maximum or 30ml/kg (max 2.5L)
    • Do not remove the aspiration device until decision made that the patient will not require further drainage      

    Post proscedure care

    Reassess ABCs

    • Consider need for further analgesia
    • Organise appropriate patient disposition