🫁 Chapter 140: Needle Thoracocentesis & Tube Thoracostomy

Emergency needle decompression (tension pneumothorax) · Needle thoracocentesis (pleural fluid drainage) · Tube thoracostomy (chest tube) · Indications · Seldinger vs surgical technique · Chest tube sizes · Water seal · Removal criteria · Complications

🔍 Core Concepts: Needle Thoracocentesis & Tube Thoracostomy

📌 Needle Decompression (Tension Pneumothorax)
Emergency: 2nd intercostal space, midclavicular line. Needle above 3rd rib (avoid neurovascular bundle). Follow with chest tube.
📌 Needle Thoracocentesis (Pleural Fluid)
Diagnostic or therapeutic drainage of pleural effusion/empyema. Ultrasound-guided. Site: posterior axillary line, 7th-9th ICS.
📌 Tube Thoracostomy (Chest Tube)
Indications: pneumothorax (ventilated patients, large, unstable), hemothorax, empyema, chylothorax, post-op. Seldinger or surgical technique.
📏 Chest Tube Sizing (French)
Premature: 8-10F, Newborn: 8-10F, 6 months: 10-12F, 1 year: 10-14F, 3y: 12-16F, 6y: 12-16F, 8y: 14-20F, 10y: 20-28F, 12y+: 28-32F.
💧 Chest Drainage System
Water seal (one-way valve). Suction may be added. No clamping (risk tension pneumothorax). Fluctuations (tidaling) indicate patency.
⚠️ Complications
Bleeding (intercostal artery), lung perforation, re-expansion pulmonary oedema, infection, subcutaneous emphysema, nerve injury.
🚫 Removal Criteria
No air leak for 24h, lung re-expanded on CXR, drainage minimal (<1-2 mL/kg/day, serous), patient stable.

🩺 Stepwise Chest Drainage Procedures

1
Needle decompression (tension pneumothorax)
Identify: hypotensive, absent breath sounds, distended neck veins, tracheal deviation. Needle (14-16G) in 2nd ICS, midclavicular line, above 3rd rib. Immediate improvement. Then place chest tube.
2
Needle thoracocentesis (pleural fluid)
Ultrasound-guided. Site: posterior axillary line, 7th-9th ICS (triangle of safety). Local anaesthesia. Aspirate fluid for diagnostic or therapeutic relief.
3
Tube thoracostomy – Seldinger technique
Ultrasound-guided. Insert needle, pass guidewire, dilate, insert pigtail/chest tube. Secure, connect to water seal. Confirm with CXR.
4
Surgical (open) chest tube insertion
Incision in triangle of safety (4th-5th ICS, anterior axillary line). Blunt dissection through intercostal muscles, enter pleura with finger. Insert tube, aim apically (pneumothorax) or basally (fluid). Secure, connect to drainage system.
5
Post-placement management & removal
Monitor output, tidaling. No clamping. Chest X-ray to confirm position. Remove when no air leak for 24h, lung expanded, output low. Remove during expiration or Valsalva, cover immediately.