Optimizing anatomic site selection for needle decompression and chest tube placement for pneumothorax in pregnancy
Beverly Claire Tse, Tonya Tucker, Ava G. Holland, Benjamin Sutton, Caroline Berberian, Poorna Balakumar, Kasey McKenna, Andrea D. ShieldsAbstract
Introduction
Tension pneumothorax can cause life‐threatening respiratory and cardiac complications. Prompt decompression is essential, with current guidelines favoring the fourth or fifth intercostal space (ICS) at the anterior axillary line (AAL) over the traditional second ICS at the midclavicular line (MCL). In pregnancy, physiologic changes such as diaphragm elevation and altered thoracic anatomy may influence the safety and effectiveness of these sites. The primary objective of this study is to determine the optimal location for needle decompression and chest tube placement in pregnancy utilizing chest x‐ray (CXR) and computed tomography (CT) imaging.
Methods
Imaging from pregnant patients with singleton pregnancies between 6 and 41 weeks was retrospectively analyzed. CXRs were used to measure diaphragm position relative to the anterior ribs and ICS at the MCL. CT scans were used to assess diaphragm position at the AAL, chest wall thickness (CWT), and distance to vital structures (DVS) at the second ICS (MCL) and the fourth and fifth ICS (AAL).
Results
A total of 90 CXRs and 56 CT scans were analyzed. The diaphragm was located between the fourth–eighth ribs at the MCL and the fifth–eighth ribs at the AAL, with no statistical difference when stratifying by trimester. Mean CWT was greatest at the second ICS (MCL) and thinnest at the fifth ICS (AAL) with a statistically significant difference across sites ( p < 0.001). The shortest mean DVS was at the left fifth ICS (AAL). On the right, the liver was in the needle path in 31% of cases at the fifth ICS, while at the fourth ICS both abdominal structures and the diaphragm were not encountered bilaterally.
Conclusion
Needle decompression site in pregnancy requires balancing safety and procedural success. The second ICS (MCL) offers the greatest DVS but may fail due to increased CWT. The fourth and fifth ICS (AAL) offer thinner chest walls but pose greater risk of organ injury, particularly on the left where the DVS is the least. Due to the thinner chest wall and lack of abdominal structures, the fourth ICS (AAL) may be the optimal decompression site in pregnancy.