Needle aspiration is a technique that allows aspiration of air via the chest wall without insertion of a chest drain (thoracostomy tube).
Outcome
Overall, for primary spontaneous pneumothoraces, the initial success rate of the procedure is no different to that of chest drainage (60-70%). Successful aspiration is associated with a much higher likelihood of discharge than chest drain insertion and fewer complications have been reported.
Following successful aspiration, patients with primary pneumothoraces should have a short period of observation in the ED before discharge.
Recurrence rates are similar at 7 days and 1 year compared to thoracostomy tube insertion. [14]
Needle aspiration is no longer recommended for secondary pneumothorax as per 2023 BTS guidelines. [21]
BTS Guidelines
The BTS guidelines recommend use of a cannula no greater than 16G in diameter for aspiration though evidence that larger cannulae are more likely to cause a persistent pleural leak is limited. It should be remembered that narrower cannulae are also shorter and may not be long enough to reach the thoracic cavity in larger patients.
Insertion point
The insertion point is the 2nd intercostal space in the mid-clavicular line. The second intercostal space is found by locating the end of the 2nd rib medially where it attaches at the manubrio-sternal angle. The rib space below the 2nd rib is the 2nd intercostal space. An alternative site is in the ‘safe triangle’. We describe this on the next page.
Method
- Inform the patient about the planned procedure and obtain written consent
- Position the patient in a slightly reclined position
- Identify the insertion point (mid-clavicular line in the 2nd intercostal space) and mark with a pen
- Put on a gown and sterile gloves, clean the area with antiseptic solution and apply drapes
- Using an aseptic technique, infiltrate a few millilitres of 1% lidocaine subcutaneously
- Insert a commercially available kit or a size 14g cannula (attached to a 10 ml syringe containing sterile normal saline) through the chest wall at the insertion point, in a horizontal plane.
- Aspiration of air confirms correct placement
- Remove the trochar
- Attach the cannula to a short connecting piece of tubing and a 3-way connector
- Aspirate via a 50 ml syringe, turn the tap and dispel the air into the atmosphere
- Turn the tap again and aspirate another 50 ml from the pleural cavity
- Continue until the patient coughs, 2.5 litres have been aspirated or no more air can be aspirated
- Repeat the chest radiograph
- If the procedure is successful, the cannula should be removed and a small occlusive dressing placed over the insertion site
- If the procedure is unsuccessful proceed to insertion of a thoracostomy tube
Needle Aspiration of Pneumothorax by the NEJM (Video) [16]
Key points
- Failure to attach the cannula to a connecting piece of tubing increases the likelihood of tube kinking or ‘accidental removal’
- A minimum of two persons are required for this procedure, one to manually secure the cannula and turn the connector, the other to perform the aspiration
- This is a time consuming procedure (50 times x 50 ml) but success rates are relatively high
- Beware of turning the tap the wrong way and inserting air into the pleural cavity
- The syringe gets very warm from the friction and increasing effort is required with each aspiration