Determination of the appropriate catheter length for needle thoracostomy by using computed tomography scans of trauma patients in Japan

Abstract

Background

Previous studies reported a high failure rate in relieving tension pneumothorax by needle thoracostomy, because the catheter was not sufficiently long to access the pleural space. The Advanced Trauma Life Support guideline recommends needle thoracostomy at the second intercostal space in the middle clavicular line using a 5.0-cm catheter, whereas the corresponding guideline in Japan does not mention a catheter length. It is necessary to measure the chest wall thickness (CWT) and determine the appropriate catheter length taking the differences of habitus in race and region into consideration. This study was designed to analyse CWT in Japanese trauma patients by computed tomography and to determine the percentage of patients whose pleural space would be accessible using a 5.0-cm catheter.

Patients and methods

We performed a retrospective review of chest computed tomography of 256 adult Japanese trauma patients who were admitted to the level 1 trauma centre of Tokai University Hospital in Kanagawa, Japan between January and July 2008. In 256 patients, the CWT at 512 sites (left and right sides) was measured by chest computed tomography at the second intercostal space in the middle clavicular line. The frequency of measurement sites <5.0 cm was calculated simultaneously.

The samples were divided according to gender, side (left and right), abbreviated injury scale (<3, ≧3), arm position during examination (up/down), and the existence or non-existence of associated injuries (pneumothorax, subcutaneous emphysema, and fracture of the sternum and ribs); the CWT of each group was compared.

Results

The mean CWT measured in 192 males and 64 females was 3.06 ± 1.02 cm. The CWT values at 483 sites (94.3%) were less than 5.0 cm. The CWT of females was significantly greater than that of males (3.66 cm vs. 2.85 cm, p < 0.0001), and patients with subcutaneous emphysema had greater CWTs than those without it (4.16 cm vs. 3.01 cm, p < 0.0001).

Conclusion

The mean CWT at the second intercostal space in the middle clavicular line was 3.06 cm. It is likely that over 94% of Japanese trauma patients could be treated with a 5.0-cm catheter.

Introduction

Tension pneumothorax is a life-threatening condition that requires rapid and effective treatment to relieve the intrapleural pressure. The Advanced Trauma Life Support (ATLS) guideline proposed by the American College of Surgeons recommends that needle thoracostomy (NT) should be performed at the second intercostal space (ICS) in the middle clavicular line (MCL) using an catheter more than 5 cm in length.¹ Previous studies suggest a high rate (30–38%) of treatment failure using this procedure in a prehospital setting.2, 8 One of the factors for treatment failure is the short length of the catheter compared to the chest wall thickness (CWT) at the second ICS in the MCL.5, 14, 15, 20

Studies on CWT measured by computed tomography (CT) scan and ultrasound tests have been carried out in the United States of America (USA), Canada, and the United Kingdom (UK). In these studies, it has been reported that 4–50% of patients have a CWT >4.5 cm4, 22, 24 whilst for 22.7–33% it is >5.0 cm,12, 16 suggesting that there are differences between the CWTs of patients from different nations. Meanwhile, no similar study regarding CWT exists for Asian nations, including Japan. The Japan Advanced Trauma Evaluation and Care (JATEC™) – Japan's trauma guideline published in 2002 – does not refer to a specific catheter length.¹³ The failure rate of NT for tension pneumothorax is poorly understood in Japan. It is necessary to clarify CWT and to determine the appropriate length of the catheter taking differences of habitus in race and region into consideration.

This study was designed to analyse the CWT at the second ICS in the MCL of Japanese trauma patients by computed tomography scans and to evaluate the recommended catheter length of 5.0 cm in ATLS. This study was reviewed and approved by the institutional review board of Tokai University School of Medicine.