Breathing Skills 5:
Needle Thoracostomy
Needle thoracostomy is used to decompress the chest when a patient is deteriorating because of a tension pneumothorax. It is inserted on the side of the pneumothorax.
Use the Cook needle thoracostomy set with a syringe attached.
- Feel the third rib on the side of the tension pneumothorax at the midclavicular line. Hold the syringe and needle in your dominant hand. Extend your index finger on the needle/cath with the tip of the finger 1 inch from its tip. Insert the needle through the skin and onto the rib. Grasp the needle 1 inch from the point and step the needle over the top of the rib and into the chest. The finger hold prevents the needle from going in too far.
Clinicians should be aware that recent evidence has suggested that chest wall thickness is increasing. Make sure that needle length is sufficient for body habitus.
- Cast off the cannula into the chest over the needle as if starting an IV. Insert it to its hub.
- Remove the needle and listen for air ejection caused by the tension pneumothorax.
- Attach a flutter valve (Heimlich) to the cannula with the tubing provided in the set.
- Apply positive pressure ventilation to re-expand the lung. Insert a chest tube and remove the catheter. Connect the chest tube to suction to re-expand the lung.
Consider tension pneumothorax in any shocky patient. Observe for abnormal chest excursion with hyper-resonance, distended neck veins (if the patient is not hypovolemic), tracheal deviation to the opposite side, and loss of breath sounds. These findings might not be present, so if the likelihood of a tension pneumothorax is present, insert a needle and listen for a rush of air.
Contents of the needle thoracostomy kit: A Heimlich valve; syringe to be used as a handle when inserting the needle/cath; a needle/cath (8.5 French); connecting tubing; and a patch that can be placed around the shaft of the cannula to provide a surface to which tape can be placed to secure it.
Reference
- Patrick VC. Emergency needle thoracentesis in Emergency nursing procedures, 2nd ed. Proehl JA, editor. Philadelphia, Pa: WB Saunders, 1999, 130-132.