Hemodynamically Unstable

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Hemodynamically unstable with concern for tension pneumothorax:

Much like the diagnostic workup, patients with pneumothorax should be managed based on clinical picture. Unstable patients with tension physiology should undergo immediate needle decompression. A 2015 meta-analysis showed that the standard needle length, 3.8 cm, is long enough to enter the pleural space in only 50% of patients, but a needle length of 6.5 cm is long enough to access the pleural space in 95% of patients.$^{25}$ As of the 10th edition of the ATLS guidelines, the optimal site for insertion of the needle for decompression is the fourth or fifth intercostal space along the anterior axillary line.$^{26}$ This change from previous ATLS guidelines was made after a meta-analysis of 13 studies examining chest wall thickness and needle thoracostomy positioning found that the anterior axillary approach had the lowest failure rate of needle decompression sites.$^{20,24}$ This is due to the fact that patients with a larger body habitus may present a greater challenge in finding anatomic landmarks and in determining the correct depth of needle insertion from the midclavicular approach, but the pleural space can still be accessed successfully from the fourth or fifth intercostal spaces along the anterior axillary line.$^{24}$ Decompression can also be approached along the midaxillary line at the fourth and fifth intercostal spaces. Needle decompression at the midclavicular line at the second intercostal space should be reserved for children.

For tension pneumothoraces and larger pneumothoraces in symptomatic patients, TT is the definitive treatment for air evacuation. The chest tube should be placed at the midaxillary line in the fourth or fifth intercostal space with the tube directed anteriorly to allow for drainage of the pneumothorax.$^{26}$ Standard chest tube size ranges from 28F to 40F; pigtail chest tube size generally ranges from 8F to 20F.$^{26}$

Positioning and adequate analgesia are central to successful placement of a chest tube. The patient’s arm should be positioned above the head to allow full access to the lateral chest wall. The skin should be anesthetized where the incision will be made, and lidocaine should be administered along the entire tract that the chest tube will traverse, from skin to parietal pleura. The rib periosteum and the parietal pleura are pain-sensitive structures that require a large amount of local anesthetic.

Patients undergoing TT should be counseled on tube-related complications, as well as the possible need for the insertion of additional chest tubes. (See Table 2.) The most common complications associated with chest tube insertion are bleeding and intercostal neuralgia, although there are also more-severe and morbid complications that can occur due to improper positioning or premature tube removal.$^{27}$ Risk of damage to surrounding structures can be minimized with proper insertion technique. Although re-expansion pulmonary edema is a rare complication, it carries a high degree of morbidity and mortality.$^{26}$

Data from Mohammed HM. Chest tube care in critically ill patient: a comprehensive review. Egyptian Journal of Chest Diseases and Tuberculosis. 2015;64(4):849-855.