Page 26 - JSOM Winter 2025

TABLE 3 Characteristics of Needle Decompression Failures
Ending pressure, Time to lowest
Patient Age Sex Sternotomy Pacemaker Side Location mmHg Audibility pressure, s
10ga failure
1 91 F N N L AAL 8 Silent 30.2
2 73 M N N R MCL 8 Silent 84.7
3 85 F N N L MCL 9 Silent 42.0
4 93 F N N R AAL 6 Yes, needle removed 14.5
5 93 F N N L AAL 6 Yes, needle removed 21.0
14ga failure
1 91 F N N L MCL 9* Silent 38.0
2 95 M N N R AAL 6 Yes, needle removed 30.5
3 85 M N N R MCL 8 Yes, needle in place 58.3
4 93 M N N R MCL 5 Yes, needle removed 51.7
5 90 F Y Y L MCL 6 Yes, needle removed 96.9
*Procedure was performed and failed with the other side of the hemithorax being excluded due to a large pleural effusion with no lung sliding
on ultrasound.
AAL = anterior axillary line; F = female; ga = gauge; M = male; MCL = midclavicular line; Y = yes.

unknown. Prior to each procedure, lung sliding was verified Limitations
via ultrasound, indicating that a large pleural effusion was While this investigation established that 10ga needle/catheter
unlikely to have contributed. However, the presence of under- units were faster to decompress a tPTX than 14ga needle/
lying pathophysiologic factors, such as localized pleural ad- catheter units, several limitations should be noted. First, only
hesions, thickened pleura, or heterogeneous tissue resistance, one NDC kit manufacturer was used for each gauge (10ga
may have impeded complete decompression. Additionally, and 14ga). Different brands or designs of needle/catheter units
there may have been procedural factors such as partial cath- could yield different outcomes, but similar physical specifica-
eter occlusion, malposition despite correct landmarking, or tions should yield similar results. Second, auditory detection
dynamic airway collapse during decompression that were not of air release during NDC is subjective. Although there were
readily apparent during real-time observation. These findings several observers in the room during the procedures, audible
highlight the complexity of achieving consistent decompres- responses are subject to interobserver variability and thus
sion outcomes, even under controlled conditions, and warrant introduce potential biases and inconsistencies in the results.
further investigation into both anatomical and procedural Third, cadavers are effective anatomic static intrathoracic
variables that may affect NDC success. pressure models, but they do not replicate the dynamic physi-
ology of a dying patient in extremis.
The TCCC guidelines recommend decompression with place-
ment of a 10ga or 14ga needle/catheter units in either anatom- Additionally, cadaver specimens are frequently advanced in
ical position “all the way to the hub and hold it in place for age, beyond that of typical trauma patients, and the varia-
5–10s to allow decompression to occur.” This practice is not tions inherent to this population would be expected to affect
3
consistent with Emergency Medicine and prehospital literature, outcomes. This was controlled by performing ventilation lung
which instructs that the needle should be advanced only until slide confirmation. Specifically, some hemithoraces were ex-
the pleura is punctured and does not advise leaving the needle cluded from the study due to anatomical and pathological ab-
in for decompression. 25–27 This insertion of a 3.25-inch needle normalities that precluded the creation of the tPTX physiology
to its maximal depth, particularly in the 5th ICS AAL, has been necessary for the experiment. Finally, this study was conducted
shown to risk iatrogenic injury in patients with thinner hemi- in a controlled laboratory setting (markedly dissimilar to bat-
17
thoraces. Moreover, this study established that NDC can be tlefield settings, prehospital scene work, or a busy Emergency
performed successfully 91% of the time with a depth-limiting Department), which likely resulted in higher successful NDC
technique that avoids hubbing the 3.25-inch needle. rates.
A secondary outcome measure in this investigation was the au- Conclusion
dibility of NDC between 10ga and 14ga needle/catheter units.
The majority of 14ga NDCs did not have audible airflow until Tension pneumothorax NDC success rates were similar be-
the needle was removed. This observation indicates that NDC tween 10ga and 14ga fenestrated needle/ catheter units; how-
with the 14ga needle/catheter unit may not provide audible ever, 10ga units achieved this approximately 17s faster. These
confirmation of correct intrathoracic placement until the nee- seconds are potentially lifesaving, and recommendations for
dle is removed. The findings from this study indicate that, al- NDC needle/catheter unit specifications should be adjusted
though both catheter sizes reliably produce an audible rush accordingly. Given the excellent success rates for the depth-
of air, the 10ga needle/catheter unit has a higher likelihood of limiting technique across both common NDC sites, the po-
audible air release during initial NDC decompression, with the tentially dangerous practice of “hubbing” the needle/catheter
needle still in place. Audibility of tPTX release with the needle unit should be abandoned. Furthermore, the current recom-
in place may correlate with NDC success rates, but this was mendations for leaving the needle in place for up to 10s after
not within the scope of this study and may be appropriate for insertion should be reexamined for impact on NDC speed and
future investigation. efficacy.

24 | JSOM Volume 25, Edition 4 / Winter 2025