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Thoracicentasis from the book of surgeryBailey and love

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needle thoracocentesis tension pneumothorax second intercostal space midclavicular line

This diagnostic image is an anteroposterior (AP) chest X-ray illustrating the clinical management of a tension pneumothorax. The radiograph shows the thorax of a pediatric patient with an 18G intravenous cannula (indicated by a black arrow) inserted into the upper left lung field, specifically at the level of the second intercostal space in the mid-clavicular line. This device was utilized for emergent needle decompression. Significant radiographic findings include bilateral lung fields with marked hyperinflation of the left lung relative to the right, consistent with post-decompression status. The mediastinum appears centrally located, though evidence of previous tension can be inferred by the clinical context. Other visible features include a midline tracheal tube and gastric gas bubble. This image serves as an educational example of emergency procedural intervention for life-threatening respiratory distress and the visual confirmation of decompression device placement in a critical care setting.

This diagnostic image is an anteroposterior (AP) chest X-ray illustrating the clinical management of a tension pneumothorax. The radiograph shows the thorax of a pediatric patient with an 18G intravenous cannula (indicated by a black arrow) inserted into the upper left lung field, specifically at the level of the second intercostal space in the mid-clavicular line. This device was utilized for emergent needle decompression. Significant radiographic findings include bilateral lung fields with marked hyperinflation of the left lung relative to the right, consistent with post-decompression status. The mediastinum appears centrally located, though evidence of previous tension can be inferred by the clinical context. Other visible features include a midline tracheal tube and gastric gas bubble. This image serves as an educational example of emergency procedural intervention for life-threatening respiratory distress and the visual confirmation of decompression device placement in a critical care setting.

A clinical photograph of a male torso demonstrating anatomical landmark identification for needle decompression. A series of black dots are superimposed over the left pectoral region, representing various identification attempts of the second intercostal space at the mid-clavicular line (MCL) by medical practitioners. The dots vary in size to indicate frequency, with larger dots representing areas selected by multiple participants. A tan star icon denotes the anatomically correct location of the second intercostal space at the mid-clavicular line. The visual serves to illustrate common inaccuracies in identifying thoracic landmarks for emergent procedures such as tension pneumothorax decompression. The image highlights the discrepancy between clinical practice and anatomical accuracy in a medical education context.

A clinical photograph of a male torso demonstrating anatomical landmark identification for needle decompression. A series of black dots are superimposed over the left pectoral region, representing various identification attempts of the second intercostal space at the mid-clavicular line (MCL) by medical practitioners. The dots vary in size to indicate frequency, with larger dots representing areas selected by multiple participants. A tan star icon denotes the anatomically correct location of the second intercostal space at the mid-clavicular line. The visual serves to illustrate common inaccuracies in identifying thoracic landmarks for emergent procedures such as tension pneumothorax decompression. The image highlights the discrepancy between clinical practice and anatomical accuracy in a medical education context.

This diagnostic image consists of two axial non-contrast chest CT slices (a and b) demonstrating anatomical measurements relevant to needle thoracentesis safety. Figure (a) shows a cross-section at the level of the right second intercostal space midclavicular line (ICS-MCL), while figure (b) shows the level of the fifth intercostal space mid-axillary line (ICS-MAL). Both images feature labeled points A, B, and C with corresponding measurement vectors. Point A is located on the external skin surface, Point B is at the parietal pleura, and Point C marks the border of a vital mediastinal structure (such as the aorta or pulmonary vessel). The red segment AB represents the Chest Wall Thickness (CWT), indicating the radial depth from the skin to the pleural space. The white line segment AC represents the 'smallest depth to vital structure' (DVSclose), which measures the minimum distance from the skin surface to intrapleural vital organs. These images illustrate the clinical significance of needle length selection to avoid iatrogenic injury to cardiac or vascular structures during thoracic decompression procedures.

This diagnostic image consists of two axial non-contrast chest CT slices (a and b) demonstrating anatomical measurements relevant to needle thoracentesis safety. Figure (a) shows a cross-section at the level of the right second intercostal space midclavicular line (ICS-MCL), while figure (b) shows the level of the fifth intercostal space mid-axillary line (ICS-MAL). Both images feature labeled points A, B, and C with corresponding measurement vectors. Point A is located on the external skin surface, Point B is at the parietal pleura, and Point C marks the border of a vital mediastinal structure (such as the aorta or pulmonary vessel). The red segment AB represents the Chest Wall Thickness (CWT), indicating the radial depth from the skin to the pleural space. The white line segment AC represents the 'smallest depth to vital structure' (DVSclose), which measures the minimum distance from the skin surface to intrapleural vital organs. These images illustrate the clinical significance of needle length selection to avoid iatrogenic injury to cardiac or vascular structures during thoracic decompression procedures.

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Thoracocentesis - Bailey and Love's Short Practice of Surgery (28th Edition)

Bailey and Love covers thoracocentesis (also called needle thoracocentesis or thoracic needle decompression) primarily in two contexts: emergency management of tension pneumothorax and the broader management of pneumothorax and pleural effusion. Here is a full account drawn directly from the text.

1. Definition and Context

Thoracocentesis refers to the insertion of a needle or cannula into the pleural space to relieve either air (in tension pneumothorax) or fluid (pleural effusion). Bailey and Love addresses both forms across its thoracic and trauma chapters.

2. Tension Pneumothorax - Needle Thoracocentesis

Pathophysiology

A tension pneumothorax develops when a "one-way valve" air leak occurs either from the lung or through the chest wall. Air is sucked into the thoracic cavity without any means of escape, completely collapsing and then compressing the affected lung. The mediastinum is displaced to the opposite side, decreasing venous return and compressing the opposite lung.
Common causes:
  • Penetrating chest trauma
  • Blunt chest trauma with a parenchymal lung injury and air leak that did not spontaneously close
  • Iatrogenic lung injury (e.g., due to central venepuncture)
  • Mechanical positive-pressure ventilation

Clinical Features

The clinical presentation is dramatic:
  • Increasing restlessness, tachypnoea, dyspnoea
  • Distended neck veins (similar to pericardial tamponade)
  • Hyper-resonance and decreased or absent breath sounds over the affected hemithorax
  • Tracheal deviation - a late finding, not necessary to confirm diagnosis
Important: Tension pneumothorax is a clinical diagnosis and treatment should never be delayed by waiting for radiological confirmation. Always treat it with a high index of suspicion.
Radiological appearance of tension pneumothorax
Radiological appearance of a tension pneumothorax (Bailey and Love, Fig. 29.3)

Needle Thoracocentesis Technique (Tension Pneumothorax)

Treatment consists of immediate decompression:
  • Historically: rapid insertion of a large-bore cannula into the 2nd intercostal space in the mid-clavicular line of the affected side, followed by insertion of a chest tube through the 5th intercostal space in the anterior axillary line.
  • Current teaching advocates undertaking decompression in the "safe triangle" - defined:
    • Posteriorly by latissimus dorsi
    • Anteriorly by the lateral border of pectoralis major
    • Inferiorly by a line perpendicular to the nipple going to the back, just anterior to the mid-axillary line
  • In extremis: a finger thoracostomy at the same location.
Anatomical landmark identification for needle decompression at 2nd ICS midclavicular line
CT showing chest wall thickness measurements for needle thoracentesis safety

3. Inserting and Managing a Chest Drain (Intercostal Tube Thoracocentesis)

For non-emergency drainage, Bailey and Love describes the formal chest drain insertion technique in detail.

Site of Insertion - "Triangle of Safety"

The safest site for drain insertion lies in the triangle:
  • Anterior to the mid-axillary line
  • Above the level of the nipple
  • Below and lateral to the pectoralis major muscle
This will ideally find the 5th intercostal space.

Step-by-Step Technique

  1. Sterility - Meticulous attention to sterility throughout
  2. Anaesthesia - Adequate local anaesthesia to include the pleura
  3. Skin incision - Sharp dissection to cut only the skin
  4. Blunt dissection - With artery forceps down through the muscle layers (serratus anterior and the intercostals only)
  5. Oblique tract - So that the skin incision and the hole in the parietal pleura do not overlie each other; the drain is in a short tunnel, reducing the chance of entraining air
  6. Direction of drain:
    • For pneumothorax and haemothorax: aim towards the apex of the lung
    • For pleural effusion or empyema: aim nearer the base
  7. Pass over the upper edge of the rib - to avoid the neurovascular bundle beneath the rib
  8. Retaining stitch - Secure but should not obliterate the drain
  9. Vertical mattress suture - Inserted for later wound closure (vital for pneumothorax; omit if drain is for empyema, as that tract should lie open)
  10. Underwater seal - Connect drain to an underwater seal device which functions as a one-way valve
  11. Confirm with CXR - After completion, take a chest radiograph to check the drain has achieved its objective

Key Principles

  • It is preferable not to apply suction to the drain or clamp it. The danger is that the clamp may be applied for transport and forgotten.
  • A bubbling drain should (almost) never be clamped.
  • Remove the drain when it no longer has a function.
Summary Box 60.2 - Suction on a pleural tube:
  • Be aware! Inserting the drain, and not the suction, is the life-saving manoeuvre
  • If the lung is reluctant to expand, suction deviates the mediastinum
  • If the lung is fragile, it may worsen an air leak

4. Pneumothorax - Classification and Management

Types

TypeDescription
Primary spontaneous (PSP)Young people (teens-late 20s); 75% in tall young men; due to leaks from blebs/bullae at apex of upper lobe
Secondary spontaneous (SSP)Older patients with underlying lung disease (e.g., emphysema, TB, cavitating disease, necrosing tumours)
TraumaticFollowing blunt or penetrating chest trauma
IatrogenicCentral line insertion, etc.
TensionAny aetiology with build-up of positive pressure; completely collapses lung, flattens diaphragm, distorts mediastinum, compromises venous return

Recurrence Rates

  • After a first event: only ~1/3 experience recurrence
  • After a second episode: ~1/2 go on to a third episode
  • Three episodes: probably repeated recurrences thereafter

Indications for Surgical Intervention (Summary Box 60.1)

  • Second ipsilateral pneumothorax
  • First contralateral pneumothorax
  • Bilateral spontaneous pneumothorax
  • Pneumothorax fails to settle despite chest drainage
  • Spontaneous haemothorax
  • Professions at risk (e.g. pilots, divers)
  • Pregnancy

Drain Size

Current recommendations focus on the use of small bore (10-14 Fr) chest drains, usually of a Seldinger type, inserted ideally under ultrasound guidance. Knowledge of the "surgical" chest drain technique remains required.

5. Pleural Effusion

Pleural effusions are divided into:
  • Exudates - protein >30 g/L; characterised further by glucose, pH, and LDH content
  • Transudates - protein <30 g/L

Malignant Pleural Effusion

Common causes include:
  • Lung cancer (direct pleural involvement; usually signifies disease beyond surgical cure)
  • Primary pleural malignancy - malignant mesothelioma (consequence of asbestos exposure; presents with breathlessness, pain, systemic malignancy features)
  • Mediastinal lymphatic involvement (e.g. breast cancer - no direct pleural disease, but lymphatic obstruction disturbs pleural fluid balance)

6. Surgical Management of Pneumothorax

VATS (video-assisted thoracoscopic surgery) or open thoracotomy. Three objectives:
  1. Deal with any leaks from the lung
  2. Search for and obliterate any blebs and bullae
  3. Make visceral pleura adherent to parietal pleura (so subsequent leaks are contained)

Methods of Pleural Adhesion

  1. Pleurectomy - systematically stripping the parietal pleura from the chest wall
  2. Pleural abrasion - a scourer scrapes off the slick surface of the parietal pleura
  3. Chemical pleurodesis - usually talc

6. Emergency Context - Thoracocentesis as Damage Control

Bailey and Love also emphasises needle thoracocentesis in the context of damage control surgery (DCS) and field hospital care:
"A needle thoracocentesis will relieve a tension pneumothorax and a chest drain will be needed before a patient with a significant chest injury is transferred by air."
This is classified under "Emergency care for immediate life-threatening injuries" alongside endotracheal intubation, tracheostomy, and closure of open pneumothorax.
Bailey and Love's Short Practice of Surgery, 28th Edition - Chapter 29 (Trauma/Emergency Thoracic Injuries) and Chapter 60 (Thoracic Surgery)
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