Meta-analysis of the optimal needle length and decompression site for tension pneumothorax and consensus recommendations on current ATLS and ETC guidelines
WSES (meta-analysis + consensus) · 2025 · international
Source and licence
- Authors
- Suhaib J. S. Ahmad, Jason R. Degiannis, Marion Head et al.
- Title
- Meta-analysis of the optimal needle length and decompression site for tension pneumothorax and consensus recommendations on current ATLS and ETC guidelines
- Journal
- World Journal of Emergency Surgery : WJES, 2025
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC12087068
Licence statement of the original publication
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
We found no explicitly labelled recommendations in this publication; its recommendations are in the running text of the original.
Abstract
Background: Tension pneumothorax (TP) is a life-threatening condition. The immediate recommended management is needle decompression (ND), followed by the insertion of an intercostal chest drain. The European Trauma Course (ETC) and the Advanced Trauma Life Support (ATLS) guidelines differ on needle size and decompression site, creating clinical uncertainty. This meta-analysis aims to explore the optimal approach for emergency needle decompression in TP.
Methods: This meta-analysis followed the PRISMA 2020 guidelines. It included English-language RCTs, cohort, case–control, cross-sectional studies, and case series with more than six patients. Studies on adults undergoing needle decompression therapy for TP or with chest wall thickness measurements were included. Ovid MEDLINE, Embase, and Web of Science databases were searched until May 31, 2024. Data were extracted, assessed for quality using OCEBM and GRADE, and analyzed using SPSS and OpenMeta with random-effects models. Primary outcome: needle decompression failure rate. Secondary outcomes: patient demographics, cannula size, and chest wall thickness comparisons.
Results: This review analyzed 51 studies on needle decompression for TP, with a weighted mean patient age of 36.67 years. Radiological data from 24 studies (n = 8046) indicated a 32.84% failure rate for needle penetration into the pleural cavity (I2: 99.72%). Increased needle length reduced failure rates by 7.76% per cm. No significant differences in chest wall thickness between genders were observed (T-test, p = 0.77), but thickness at the 5th anterior axillary line (5AAL) and 5th midaxillary line (5MAL) was less than at the 2nd midclavicular line (2MCL). Injury rates were higher at 5AAL than 5MAL, with strong positive correlations between needle length and injury at these sites (0.88, 0.91).
Conclusion: Based on our meta-analysis, a 7 cm needle may be appropriate for decompression of right-sided tension pneumothorax at either the 5th intercostal space along the midaxillary line or the 2nd intercostal space along the midclavicular line. For left-sided cases, given the potential risk of cardiac injury, the 2nd midclavicular line is a safer option. However, these recommendations should be interpreted with caution due to considerable heterogeneity among the included studies, potential risk of bias, and variability in measurement techniques. Clinical decisions should always be individualized, taking into account patient-specific factors.
Supplementary Information: The online version contains supplementary material available at 10.1186/s13017-025-00613-7.
Contents of the original publication
The section headings of the original.
- Introduction
- Patients and methods
- Inclusion criteria
- Exclusion criteria
- Information sources
- Search strategy
- Selection process
- Data collection process
- Data extraction
- Quality assessment
- Statistical analysis
- Primary outcome
- Secondary outcomes
- Complication rate analysis
- Synthesis methods
- Reporting bias assessment
- Certainty assessment
- Definition of clinical success of needle decompression
- Results
- Radiological chest wall thickness
- Overall failure rate of needle decompression in tension pneumothorax
- Clinical failure rate based on symptom improvement
- Clinical failure rate related to needle length and chest wall thickness as determined by CT, MRI, or ultrasound
- Assessing radiological failure rates (US/CT/MRI) of different needle lengths at different sites
- Overall trend
- Potential injury to the heart on insertion of needle thoracostomy on the left side of the thorax. Figure 8
- Discussion:
- Limitations
- Conclusion
A question about this guideline?
Medelix answers clinical questions from guidelines and studies – every statement with its source.
Are you the rights holder and object to this reproduction? Write to contact@medelix.ai and we will take the page down promptly. Imprint