Needle decompressions for pneumothorax have significant failure and complication rates. The prehospital- or emergency medical professional performs a chest drain instead. A study in Prehospital Emergency Care Vol 16 looks at overall success rates of tube thoracostomies (TT) and compares the two classical positions for tube placements. As always the numbers are small.
The researchers identified 69 patients who had diagnosed pneumothorax or hemothorax and who had their thoracotomies and tubes in the field. Out of those 19 received bilateral TT and 50 received unilateral TT, a total of 88 chest tubes. 57% of the 88 chest tubes were placed in the Monaldi position (3rd intercostal space in the midclavicular line) and 43% were put in the Bulau position (5th intercostal space in the midaxillary line).
The overall success rate for correct placement was 78%. 22% were too far in, twisted or bent. 11% had to be corrected. One of them went subcutaneously. (How did that happen?). This is in line with other studies that put the frequency of malposition to around 20%
Is that important? Not really. In the study all chests were decompressed successfully and there were no reports of any major complications such as intercostal artery bleeds or retroperitoneal placement. This is in line with studies demonstrating how complications after prehospital TT are few and the vast majority of them are of a minor nature.
There was no significant difference between the Bulau and Monaldi positions in regards to misplacement and need for tube intervention. Nor was there a difference between tube placements in the right and left sides of the chest.
But at the end of the day, do you even need the tube? For a short hop to your local level 1 trauma centre, finger-thoracotomies and refingering (is that even a word?) might be all you need. And then there´s always the old Clamshell….
The study lives here.