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Needle thoracocentesis can be a lifesaving procedure in patients with an acute tension pneumothorax. In most cases of tension pneumothorax tube thoracostomy is preferred as it is the definitive therapy, however if there is urgent hemodynamic instability a needle thoracocentesis should be performed immediately. If the patient does not have a pneumothorax, there is a 10 - 20 % chance of causing a pneumothorax with attempt at thoracocentesis. In addition, there is a risk of significant, life-threatening bleeding if the needle is not place properly.
A significant number of providers have difficulty identifying the 2nd intercostal space. In many patients the first rib is not palpable under the patient's clavicle. It has been recommended to start at the midclavicular clavicle and palpate downwards to identify the correct space.
An ultrasound study looking at the depth of the chest wall in 18 - 55 year old patients found that the mean was 3.2 cm (range 1.3 to 5.2 cm). 57 percent had chest walls greater than 3 cm and 4 percent greater than 4.5 cm. In a CT study (mean age 43.5 years), the chest wall mean on the right was 4.5 cm (+/- 1.5 cm) and on the left was 4.1 cm (+/- 1.4 cm).
Because of the chest wall depth measurements if needle thoracocentesis is unsuccessful with a 4.5 cm cannula, a longer needle should be attempted.