Pleural Decompression


 Clinical Indications:


  • To relieve tension pneumonthorax.
    • May occur in the setting of chest trauma, COPD, PPV, spontaneously
    • Consider among (H’s and T’s) in cardiac arrest. Particularly in the setting of penetrating traumatic arrest.


 Signs and symptoms include:


  • Clinical evidence of a pneumothorax


    • Absent or decreased unilateral breath sounds.
    • Other less sensitive signs include:
      • Asymmetrical chest movement with inspiration
      • Hyper-expanded chest on affected side
      • Drum like percussion on affected side
      • Increased resistance to positive pressure ventilation, especially if intubated



    • Evidence of tension physiology


      • Hemodynamic instability: shock or rapidly decreasing blood pressure




  • Elevate head of stretcher to 30 degrees.
  • Expose the entire chest.
  • Identify the second intercostal space midclavicular on the side of the pneumothorax.
    • Place finger on the clavicle at its midpoint.
    • Run this finger straight down the chest wall to locate the first palpable rib between the clavicle.
    • The second intercostal space lies just below this rib, midway between the clavicle and the nipple line.
  • Alternatively, identify the 4th or 5th intercostal space, anterior-axillary line. (Preferred location in patients with larger chest size)
    • Raise arm above and over head.
    • Identify the edge of the pectoralis muscle. (anterior axillary line)
    • The nipple line or inferior-most border of axillary hair typically represents the 4th intercostal space.
      • Consider that the nipple may be displaced inferiorly in female patients, may not correlate with the 4th ICS.
  • Cleanse the area with an alcohol or povidone-iodine swab.
  • Select a 10, 12, or 14 gauge (at least) 3" IV catheter (Pediatric: 16 gauge, 1 ¼ inch).
  • Advance the needle above the rib. (blood vessels and nerves run along the underside of the rib.)
  • As you enter the pleural space, you will feel a pop and note a rush of air expelling.
  • Advance the catheter into the chest and then withdraw the needle. Be careful not to kink the catheter.
  • Auscultate breath sounds.
  • Secure with gauze and tape.
  • Ventilate and monitor ETCO2.
  • If symptoms fail to improve, consider the site alternate to initial attempted (above), contact Online medical control
  • for further guidance.




  • Hemodynamic and respiratory stability