Penetrating thoracic trauma injuries and the use of Pneumofix

Standard clinical management of a suspected tension pneumothorax includes insertion of a cannula into the pleural cavity¹. When a patient has a tension pneumothorax, needle chest decompression can be life-saving.

There have been widespread reports of complications following needle chest decompression^5,6. Commonly used devices, such as intravenous cannula, may not be long enough to reach the pleural space or they may kink and occlude.

There are a number of important aspects to consider when performing a needle decompression for the treatment of tension pneumothorax.  These include the size of the individual chest wall, the product chosen to perform the procedure and also how certain the individual is of the tension pneumothorax diagnosis.  These three criteria include:

1. Chest wall thickness
2. Decompression failure
3. Diagnosis and safety

1. Chest wall thickness

Using an unsuitable product to perform needle chest decompression may lead to complications or be ineffective all together. Studies have shown a failure rate of standard needle chest compression using an intravenous cannula in the pre-hospital environment of up to 40%¹. The length of the needle or catheter used can be too short to reach the pleural space to release the tensioned air.

The published literature suggests that adult chest wall thickness varies quite considerably.  A mean of >4 cm depth is often quoted.  However, any product that is to be used for needle decompression would need to be able to treat all the population and not just those mean chest wall thickness of 4cm or less.  Harcke⁸ et al reported a mean chest wall thickness of 5.36 cm in US military personnel but with some individuals having a greater chest wall thickness and a maximum of 9.35 cm.  While this might seem like an extremely large chest wall thickness, military personnel are a significant market for needle decompression products due to the potential requirement for needle decompression on the battlefield.  Therefore, any product hoping to be used for the treatment of tension pneumothorax will need to be able to treat most if not all of military personnel.

2. Decompression failure

The failure rate of an needle chest decompression to effectively decompress a tension pneumothorax is well known.  Smith & Harris catheter kinking as a leading cause of failure, together with obstruction and occlusion[1].

In the military setting, these failures have also been recognised, especially during prolonged field care and medical evacuation².

The previous gold standard, needle chest decompression, has a failure rate of up to 64% (Lubin D 2013). Lubin et al¹³ (Lubin D 2013) then demonstrated superiority of a modified veress needle over a standard angiocatheter for chest decompression.  Real et al (Real 2015) demonstrated the success of the Russell PneumoFix^TM over a modified angiocatheter commonly used in the UK for needle decompression.  Hatch et al. (Hatch Q 2014) demonstrated safe and effective chest decompression with 5-mm laparoscopic trocars.

3. Safety

A study by Leigh-Smith et al (Leigh-Smith S 2005) found that any pleural injury communicating with the atmosphere via a one-way valve that opens on inspiration and closes on expiration will lead to an expanding pneumothorax.  For clinical purposes they suggest that a pneumothorax is considered to be under tension when it results in ‘‘significant respiratory or haemodynamic compromise.  In trauma a clear diagnosis can be in doubt and the study lists the diagnosis signs and symptoms of tension pneumothorax (Table 1).

As can be seen from the list of potential symptoms of tension pneumothorax, these can be difficult to appreciate in the pre-hospital setting.  Although needle decompression should only be used in patients with tension pneumothorax, one series of trauma needle decompression placements established that only about 5% of patients had tension pneumothorax (Wernick B 2015).  This suggests that in the field needle decompression can be performed when it is not always needed.  Ball (Ball CG 2010) also states that it should be realised it is easier for a physician in a controlled trauma bay to diagnose tension pneumothorax, compared with paramedics with field challenges that include suboptimal sedation, environment, vital sign monitoring and the potential pulmonary effects of altitude.  This results in decompression devices being placed with greater frequency by paramedics or field doctors than their hospital-based colleagues.

The insertion of a needle decompressing device when a tension pneumothorax is not present does create a safety issue for some products.  If a tension pneumothorax is not present, then it is likely that the lung surface is adjacent to the pleural cavity wall.  Many commonly used devices have unprotected sharp tips. In the case of such a sharp ended product being inserted through the chest wall when a tension pneumothorax is not present, there is a significant danger of piercing the lung and then causing a tension pneumothorax which was the condition the procedure was designed to treat.

A Veress needle contains a spring-loaded inner section that pushes back in contact with stiffer material such as skin or muscle and exposes the sharp cutting edge.  When in contact with less dense tissues such as lung tissue or vascular structures, the spring-loaded inner section does not retract and thereby limits any damage. Therefore, it is logical that any product used as a needle decompression device should have a safety tip such as that on a Veress needle.

Safeguard Medical offers a variety of solutions for the Respiratory element of the MARCH mnemonic. The Russell PneumoFix^TM chest decompression needle is composed of a Veress-tipped needle inserted through an 11cm or 8cm catheter, with a one-way low-pressure release valve. The Veress tip and indicator device assist with the safe insertion with a minimal risk of injuring the underlying lung, whilst the low-pressure, one-way release valve permits the release of tension pneumothorax with minimal potential of subsequent air re-entry.

Learn more about our variety of solutions in the Respiration category.

[1] Committee on Trauma, ATLS Manual 2012, 9th Edition, American College of Surgeons

[2] Zengerink , et al. 2008;

[3] Leigh Smith & Harris., 2014;

[4] Beckett, A. et al. 2011