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Review
. 2016 Apr;47(4):797-804.
doi: 10.1016/j.injury.2015.11.045. Epub 2015 Dec 13.

Chest Wall Thickness and Decompression Failure: A Systematic Review and Meta-Analysis Comparing Anatomic Locations in Needle Thoracostomy

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Free PMC article
Review

Chest Wall Thickness and Decompression Failure: A Systematic Review and Meta-Analysis Comparing Anatomic Locations in Needle Thoracostomy

Danuel V Laan et al. Injury. .
Free PMC article

Abstract

Introduction: Current Advanced Trauma Life Support guidelines recommend decompression for thoracic tension physiology using a 5-cm angiocatheter at the second intercostal space (ICS) on the midclavicular line (MCL). High failure rates occur. Through systematic review and meta-analysis, we aimed to determine the chest wall thickness (CWT) of the 2nd ICS-MCL, the 4th/5th ICS at the anterior axillary line (AAL), the 4th/5th ICS mid axillary line (MAL) and needle thoracostomy failure rates using the currently recommended 5-cm angiocatheter.

Methods: A comprehensive search of several databases from their inception to July 24, 2014 was conducted. The search was limited to the English language, and all study populations were included. Studies were appraised by two independent reviewers according to a priori defined PRISMA inclusion and exclusion criteria. Continuous outcomes (CWT) were evaluated using weighted mean difference and binary outcomes (failure with 5-cm needle) were assessed using incidence rate. Outcomes were pooled using the random-effects model.

Results: The search resulted in 34,652 studies of which 15 were included for CWT analysis, 13 for NT effectiveness. Mean CWT was 42.79 mm (95% CI, 38.78-46.81) at 2nd ICS-MCL, 39.85 mm (95% CI, 28.70-51.00) at MAL, and 34.33 mm (95% CI, 28.20-40.47) at AAL (P=.08). Mean failure rate was 38% (95% CI, 24-54) at 2nd ICS-MCL, 31% (95% CI, 10-64) at MAL, and 13% (95% CI, 8-22) at AAL (P=.01).

Conclusion: Evidence from observational studies suggests that the 4th/5th ICS-AAL has the lowest predicted failure rate of needle decompression in multiple populations.

Level of evidence: Level 3 SR/MA with up to two negative criteria.

Study type: Therapeutic.

Keywords: Needle decompression; Needle decompression location; Needle thoracostomy; Optimal positioning; Tension pneumothorax.

Figures

Figure 1
Figure 1
Anatomic Locations for Needle Thoracostomy Decompression. A denotes the currently recommended second intercostal–space midclavicular line (ICS2-MCL); B, the fourth and fifth intercostal spaces midaxillary line (ICS4/5-MAL); and C, the fourth and fifth intercostal spaces anterior axillary line (ICS4/5-AAL). (Used with permission of Mayo Foundation for Medical Education and Research.)
Figure 2
Figure 2
The Preferred Reporting Items for Systematic Reviews and Meta-analyses Flow Diagram. The diagram details the search strategy and the inclusion and exclusion criteria.
Figure 3
Figure 3
Chest Wall Thickness by Recommended Anatomic Location and Alternative Anatomic Locations. Shown are the fourth and fifth intercostal spaces–anterior axillary line (ICS4/5-AAL), the fourth and fifth intercostal spaces–midaxillary line (ICS4/5-MAL), and the second intercostal space–midclavicular line (ICS2-MCL).
Figure 4
Figure 4
Needle Thoracostomy Failure Rates by Anatomic Location. Mean (95% CI) for fourth and fifth intercostal spaces–anterior axillary line (ICS4/5-AAL), the fourth and fifth intercostal spaces–midaxillary line (ICS4/5-MAL), and the second intercostal space–midclavicular line (ICS2-MCL).

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