Urgent needle decompression

decompensated (tension) pneumothorax. Sterile procedures and local anaesthetic are desirable, but do not delay decompression if these are not immediately available.

• insert a cannula above the third rib in the midclavicular line
• remove the needle from the cannula
• insert a thoracostomy tube as soon as possible.

Catheter aspiration (thoracocentesis/pleural tap)

small volume

• Use a small-bore catheter, such as a venous catheter with a 3-way valve or a pigtail catheter, or a single-lumen central line.
• Infiltrate local anaesthetic (5 to 10 mL of 1% lidocaine) subcutaneously in an intercostal space above the fifth rib in the midaxillary line. Infiltrate local anaesthetic into deeper layers of tissue down to the pleural space (confirmed by aspiration of air into the syringe). Withdraw needle.
• Connect catheter to the needle and puncture skin at the same landmark used for the local anaesthetic. Continue until reaching the pleural space (confirmed by aspiration of air into the syringe). Remove the needle and syringe, and leave the catheter in situ.
• Aspirate until no more air is returned.
• Leave the catheter in situ and immediately repeat the chest X-ray.

Repeat the chest X-ray again in 4 hours.

• If the pneumothorax has reaccumulated, perform intercostal catheter drainage (insert chest tube and connect to an underwater seal or a Heimlich valve).
• If the pneumothorax has not reaccumulated, remove the catheter. Discharge the patient. Follow up every 2 weeks until the pneumothorax has resolved, and advise the patient to return promptly if symptoms recur.

Intercostal catheter drainage (tube thoracostomy/chest tube/chest drain)