Abstract
BackgroundRecommendations regarding decompression of tension pneumothorax in small children are scarce and mainly transferred from the adult literature without existing evidence for the paediatric population. This CT-based study evaluates chest wall thickness, width of the intercostal space (ICS) and risk of injury to vital structures by needle decompression in children.MethodsChest wall thickness, width of the intercostal space and depth to vital structures were measured and evaluated at 2nd ICS midclavicular (MCL) line and 4th ICS anterior axillary line (AAL) on both sides of the thorax using computed tomography (CT) in 139 children in three different age groups (0, 5, 10 years).ResultsWidth of the intercostal space was significantly smaller at the 4th ICS compared to the 2nd ICS in all age groups on both sides of the thorax. Chest wall thickness was marginally smaller at the 4th ICS compared to the 2nd ICS in infants and significantly smaller at 4th ICS in children aged 5 years and 10 years. Depth to vital structure for correct angle of needle entry was smaller at the 4th ICS in all age groups on both sides of the thorax. Incorrect angle of needle entry however is accompanied by a higher risk of injury at 2nd ICS. Furthermore, in some children aged 0 and 5 years, the heart or the thymus gland were found directly adjacent to the thoracic wall at 2nd ICS midclavicular line.ConclusionEspecially in small children risk of iatrogenic injury to vital structures by needle decompression is considerably high. The 4th ICS AAL offers a smaller chest wall thickness, but the width of the ICS is smaller and the risk of injury to the intercostal vessels and nerve is greater. Deviations from correct angle of entry however are accompanied by higher risk of injury to intrathoracic structures at the 2nd ICS. Furthermore, we found the heart and the thymus gland to be directly adjacent to the thoracic wall at the 2nd ICS MCL in a few children. From our point of view this puncture site can therefore not be recommended for decompression in small children. We therefore recommend 4th ICS AAL as the primary site of choice.
Highlights
Recommendations regarding decompression of tension pneumothorax in small children are scarce and mainly transferred from the adult literature without existing evidence for the paediatric population
As the heart and thymus gland were found directly adjacent to the thoracic wall at 2nd intercostal space (ICS) midclavicular line (MCL) in several children aged 0 and 5 years, this puncture site cannot be recommended unless a pneumothorax in this region is confirmed
To avoid an unnecessarily deep needle penetration, puncture should be performed under guidance by aspiration of air via a syringe and needle movement should be immediately stopped after aspiration of air
Summary
Recommendations regarding decompression of tension pneumothorax in small children are scarce and mainly transferred from the adult literature without existing evidence for the paediatric population This CTbased study evaluates chest wall thickness, width of the intercostal space (ICS) and risk of injury to vital structures by needle decompression in children. In recent years, several studies examining chest wall thickness (CWT) at the recommended insertion sites have been conducted in adult patients and found commonly used cannulas being too short for successful decompression in a high proportion of patients [6] This has led to the recommendation of using longer 7-8 cm catheters for needle thoracostomy in adult patients [7,8,9]. We aimed to evaluate the required depth for successful decompression, defined as the distance from skin to pleural space, whilst minimizing iatrogenic underlying structure injury
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