Prehospital Decompression of Pneumothorax: A Systematic Review of Recent Evidence

Abstract

Introduction: Pneumothorax remains an important cause of preventable trauma death. The aim of this systematic review is to synthesize the recent evidence on the efficacy, patient outcomes, and adverse events of different chest decompression approaches relevant to the out-of-hospital setting. Methods: A comprehensive literature search was performed using five databases (from January 1, 2014 through June 15, 2020). To be considered eligible, studies required to report original data on decompression of suspected or proven traumatic pneumothorax and be considered relevant to the prehospital context. They also required to be conducted mostly on an adult population (expected more than ≥80% of the population ≥16 years old) of patients. Needle chest decompression (NCD), finger thoracostomy (FT), and tube thoracostomy were considered. No meta-analysis was performed. Level of evidence was assigned using the Harbour and Miller system. Results: A total of 1,420 citations were obtained by the search strategy, of which 20 studies were included. Overall, the level of evidence was low. Eleven studies reported on the efficacy and patient outcomes following chest decompression. The most studied technique was NCD (n = 7), followed by FT (n = 5). Definitions of a successful chest decompression were heterogeneous. Subjective improvement following NCD ranged between 18% and 86% (n = 6). Successful FT was reported for between 9.7% and 32.0% of interventions following a traumatic cardiac arrest. Adverse events were infrequently reported. Nine studies presented only on anatomical measures with predicted failure and success. The mean anterior chest wall thickness (CWT) was larger than the lateral CWT in all studies except one. The predicted success rate of NCD ranged between 90% and 100% when using needle >7cm (n = 7) both for the lateral and anterior approaches. The reported risk of iatrogenic injuries was higher for the lateral approach, mostly on the left side because of the proximity with the heart. Conclusions: Based on observational studies with a low level of evidence, prehospital NCD should be performed using a needle >7cm length with either a lateral or anterior approach. While FT is an interesting diagnostic and therapeutic approach, evidence on the success rates and complications is limited. High-quality studies are required to determine the optimal chest decompression approach applicable in the out-of-hospital setting.

Retrospective Matched Cohort Comparison of Prehospital Finger Thoracostomy and Needle Thoracostomy Performed by Ground Emergency Medical Services

“…Intervention by out of hospital providers may be critical in reducing mortality from tension PTX prior to definitive management (e.g., tube thoracostomy). Performance of needle thoracostomy (NT) is the traditional intervention for rapid treatment of tension physiology, but recent literature has called into question both the efficacy of thoracic decompression (Robitaille-Fortin, 2021;Axtman, 2019;Martin, 2012;Kaserer, 2017) and safety due to iatrogenic injuries sustained from placement of needle thoracostomy (e.g., cardiac, great vessel, lung).…”

Matched Cohort Study of Open Thoracostomies Performed by Ground Medics

“…Performance of nee-dle thoracostomy (NT) in the prehospital setting by medics is one approach to relieve tPTX. However, the efficacy of this procedure has recently been brought into question (Robitaille-Fortin, 2021;Axtman, 2019;Martin, 2012;Kaserer, 2017). The ability of NT to deliver successful and reliable decompression of the thoracic cavity in patients with suspected tPTX remains unclear (Robitaille-Fortin, 2021).…”

“…However, the efficacy of this procedure has recently been brought into question (Robitaille-Fortin, 2021;Axtman, 2019;Martin, 2012;Kaserer, 2017). The ability of NT to deliver successful and reliable decompression of the thoracic cavity in patients with suspected tPTX remains unclear (Robitaille-Fortin, 2021). Previous studies have shown a relatively high failure rate of NT to relieve tPTX (Axtman, 2019;Martin, 2012;Kaserer, 2017).…”

“…Despite the emergence of OT in the prehospital setting, few previous studies have evaluated its outcomes (Chesters, 2016;Dickson, 2018;Massarutti, 2016;Hannon, 2020;High, 2016;Mistry, 2009;. Two recent systematic reviews found varying success with OT and several reported complications (Robitaille-Fortin, 2021;Sharrock, 2021). The objective of this study was to measure clinical outcomes for patients with chest trauma who underwent prehospital open thoracostomy (POT) by ground EMS units and also to determine if POT increased prehospital EMS time.…”