今日の臨床サポート

緊張性気胸

著者: 東裕之 福井県立病院 救命救急センター

監修: 林寛之 福井大学医学部附属病院

著者校正/監修レビュー済:2021/08/25
参考ガイドライン:
  1. 日本外傷学会・日本救急医学会:外傷初期診療ガイドライン 改訂第6版
患者向け説明資料

概要・推奨   

  1. 意識清明患者と、気管挿管し陽圧換気状態の患者では、身体所見の出現の仕方が異なる。陽圧換気状態の患者では急速な血圧低下やSpO2の低下がほぼ全例に出現するが、意識清明患者では決して頻度は高くない(推奨度1)。
  1. 胸腔穿刺が不成功に終わるのは、血液や皮下組織が詰まったり、ねじれなどが原因となることがあるが、そもそも胸壁を貫けていないということもある(推奨度1)。
  1. 日本人の胸壁は欧米人に比べ薄く、5cm未満であり、94%以上の日本人は5.0cmの留置針で治療でき得る(推奨度2)。
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
東裕之 : 特に申告事項無し[2021年]
監修:林寛之 : 講演料(メディカ出版),原稿料(羊土社)[2021年]

改訂のポイント:
  1. 定期レビューを行い、穿刺部位についての加筆修正を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 緊張性気胸とは、患側の胸腔内圧が異常に上昇した結果、患側肺の虚脱、横隔膜低位、健側への縦隔偏位、静脈還流障害による心拍出量の低下を来した状態である[1][2][3][4][5][6][7]
  1. 気胸の中でも血気胸や両側性気胸などと並び、緊急性を要する疾患であり、対応が遅れれば死に至る恐れがあるものである。
  1. 緊張性気胸になり得る患者は、①ICUでの呼吸器管理患者、②外傷患者、③心肺蘇生患者、④喘息や慢性閉塞性肺疾患(COPD)の急性増悪、⑤非侵襲的呼吸器管理患者、⑥チェストチューブの閉塞・クランプ・誤留置、⑦中心静脈穿刺後の患者[1][2]
  1. 陽圧換気開始直後のショックでは、まず鑑別すべき疾患となる。
  1. 緊張性気胸の診断ポイントは、血圧低下や頚静脈怒張といった 心タンポナーデ に似た症状や、さらにチアノーゼを認める場合もあることである。
  1. 外傷によるもので、血管の損傷を伴う場合は血気胸となり、出血性ショックにも注意が必要である[6][7]
問診・診察のポイント  
  1. 症候は、胸痛、呼吸窮迫とともに、循環不全の所見として、頻脈、低血圧などを特徴とする。

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文献 

著者: S Leigh-Smith, T Harris
雑誌名: Emerg Med J. 2005 Jan;22(1):8-16. doi: 10.1136/emj.2003.010421.
Abstract/Text This review examines the present understanding of tension pneumothorax and produces recommendations for improving the diagnostic and treatment decision process.

PMID 15611534  Emerg Med J. 2005 Jan;22(1):8-16. doi: 10.1136/emj.2003・・・
著者: Andrew MacDuff, Anthony Arnold, John Harvey, BTS Pleural Disease Guideline Group
雑誌名: Thorax. 2010 Aug;65 Suppl 2:ii18-31. doi: 10.1136/thx.2010.136986.
Abstract/Text
PMID 20696690  Thorax. 2010 Aug;65 Suppl 2:ii18-31. doi: 10.1136/thx.2・・・
著者: M Henry, T Arnold, J Harvey, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society
雑誌名: Thorax. 2003 May;58 Suppl 2:ii39-52.
Abstract/Text
PMID 12728149  Thorax. 2003 May;58 Suppl 2:ii39-52.
著者: Erin Weldon, Jen Williams
雑誌名: Emerg Med Clin North Am. 2012 May;30(2):475-99, ix-x. doi: 10.1016/j.emc.2011.10.012. Epub 2011 Nov 30.
Abstract/Text Emergency department presentations of pleural-based diseases are common, with severity ranging from mild to life threatening. The acute assessment, diagnosis, and treatment of pleural disease are critical as urgent invasive maneuvers such as thoracocentesis and thoracostomy may be indicated. The emergency physician must have a systematic approach to these conditions that allows for rapid recognition, diagnosis, and definitive management. This article focuses on nontraumatic pleural disease, including diagnostic and treatment considerations of pleural effusion, empyema, primary spontaneous pneumothorax, secondary spontaneous pneumothorax, pediatric pneumothorax, spontaneous hemothorax, and spontaneous tension pneumothorax.

Copyright © 2012 Elsevier Inc. All rights reserved.
PMID 22487115  Emerg Med Clin North Am. 2012 May;30(2):475-99, ix-x. d・・・
著者: Bruno Bernardin, Jean-Marc Troquet
雑誌名: Emerg Med Clin North Am. 2012 May;30(2):377-400, viii-ix. doi: 10.1016/j.emc.2011.10.010. Epub 2011 Dec 30.
Abstract/Text Severe chest trauma, blunt or penetrating, is responsible for up to 25% of traumatic deaths in North America. Respiratory compromise is the most frequent dramatic presentation in blunt trauma, while injuries to the heart and great vessels pose the greatest risk of immediate death following penetrating trauma. More than 80% of patients will be managed with interventions that can be performed in the emergency department. This article reviews the presentation, diagnosis, and management of the most important thoracic injuries. A structured approach to the acutely unstable patient is proposed to guide resuscitation decisions.

Copyright © 2012 Elsevier Inc. All rights reserved.
PMID 22487111  Emerg Med Clin North Am. 2012 May;30(2):377-400, viii-i・・・
著者: S Leigh-Smith, G Davies
雑誌名: Emerg Med J. 2003 Sep;20(5):495-6.
Abstract/Text A case is presented of unilateral tension pneumothorax in an awake patient who was seen in prehospital care after a significant fall. Because of extrication difficulties it was 40 minutes after the accident when he was first seen and by this stage the tension pneumothorax was well developed. Many features that are taught as "classic" of tension pneumothorax were absent but various other clinical signs were present to aid the diagnosis, and these are reviewed.

PMID 12954706  Emerg Med J. 2003 Sep;20(5):495-6.
著者: Kate Cantwell, Stephen Burgess, Ian Patrick, Louise Niggemeyer, Mark Fitzgerald, Peter Cameron, Colin Jones, Diane Pascoe
雑誌名: Injury. 2014 Jan;45(1):71-6. doi: 10.1016/j.injury.2013.06.010. Epub 2013 Jul 13.
Abstract/Text INTRODUCTION: An audit of ambulance service clinical records from 2001 to 2002 in Melbourne, Australia revealed 10 patients with tension pneumothorax on arrival at hospital which had been undetected or untreated by paramedics. The clinical practice guideline for paramedic recognition of tension pneumothorax was subsequently changed to emphasise heightened clinical suspicion of a tension pneumothorax in the setting of chest trauma, especially when patients were managed with positive pressure ventilation. This study was undertaken to determine whether the number of undetected or untreated tension pneumothoraces had decreased after the new clinical practice guideline and associated education program; if there were unintended consequences arising from earlier paramedic intervention; and what effect, if any, this change had on subsequent hospital treatment.
METHODS: Retrospective case note review of all patients requiring intercostal catheter (ICC) insertion at The Alfred Hospital, Melbourne, Australia, using records from Ambulance Victoria, the Alfred Trauma Registry and the National Coronial Information System.
RESULTS: In 2001-2002 paramedics treated 22 patients with suspected tension pneumothorax before transport to the Alfred Hospital. In 2006-2007 this number had increased to 81. There was a decrease from ten to four in the number of unrecognised or untreated tension pneumothoraces between the two time periods. No unintended or adverse consequences of prehospital needle decompression could be found. However, there was an increase in the number of patients who had prehospital needle decompression that needed further treatment for tension pneumothorax on arrival at hospital. This need for further treatment was associated with use of shorter cannulas and unilateral needle decompression by paramedics.
CONCLUSION: A small change in clinical practice guidelines, supported by an education and audit program, led to a reduction in unrecognised untreated tension pneumothoraces by paramedics without an increase in complications. Paramedics should be aware that a shorter cannula may fail to reach the pleural space and that both sides of the chest may require decompression.

Copyright © 2013 Elsevier Ltd. All rights reserved.
PMID 23859653  Injury. 2014 Jan;45(1):71-6. doi: 10.1016/j.injury.2013・・・
著者: Khaled Alrajhi, Michael Y Woo, Christian Vaillancourt
雑誌名: Chest. 2012 Mar;141(3):703-8. doi: 10.1378/chest.11-0131. Epub 2011 Aug 25.
Abstract/Text BACKGROUND: A pneumothorax is a potentially life-threatening condition. Although CT scan is the reference standard for diagnosis, chest radiographs are commonly used to rule out the diagnosis. We compared the test characteristics of ultrasonography and supine chest radiography in adult patients clinically suspected of having a pneumothorax, using CT scan or release of air on chest tube placement as reference standard.
METHODS: We searched for English literature in MEDLINE and EMBASE and performed hand searches. Two independent investigators used standardized forms to review articles for inclusion, quality (QUADAS tool), and data extraction. We calculated κ agreement for study selection and evaluated clinical and quality homogeneity before meta-analysis.
RESULTS: We reviewed 570 articles and selected 21 for full review (κ, 0.89); eight articles (total of 1,048 patients) met all inclusion criteria (κ, 0.81). All studies but one used the ultrasonographic signs of lung sliding and comet tail to rule out pneumothorax. Chest radiography data were available for 864 of 1,048 patients evaluated with ultrasonography. Ultrasonography was 90.9% sensitive (95% CI, 86.5-93.9) and 98.2% specific (95% CI, 97.0-99.0) for the detection of pneumothorax. Chest radiography was 50.2% sensitive (95% CI, 43.5-57.0) and 99.4% specific (95% CI, 98.3-99.8).
CONCLUSIONS: Performance of ultrasonography for the detection of pneumothorax is excellent and is superior to supine chest radiography. Considering the rapid access to bedside ultrasonography and the excellent performance of this simple test, this study supports the routine use of ultrasonography for the detection of pneumothorax.

PMID 21868468  Chest. 2012 Mar;141(3):703-8. doi: 10.1378/chest.11-013・・・
著者: Daniel A Lichtenstein
雑誌名: Chest. 2015 Jun;147(6):1659-70. doi: 10.1378/chest.14-1313.
Abstract/Text This review article describes two protocols adapted from lung ultrasound: the bedside lung ultrasound in emergency (BLUE)-protocol for the immediate diagnosis of acute respiratory failure and the fluid administration limited by lung sonography (FALLS)-protocol for the management of acute circulatory failure. These applications require the mastery of 10 signs indicating normal lung surface (bat sign, lung sliding, A-lines), pleural effusions (quad and sinusoid sign), lung consolidations (fractal and tissue-like sign), interstitial syndrome (lung rockets), and pneumothorax (stratosphere sign and the lung point). These signs have been assessed in adults, with diagnostic accuracies ranging from 90% to 100%, allowing consideration of ultrasound as a reasonable bedside gold standard. In the BLUE-protocol, profiles have been designed for the main diseases (pneumonia, congestive heart failure, COPD, asthma, pulmonary embolism, pneumothorax), with an accuracy > 90%. In the FALLS-protocol, the change from A-lines to lung rockets appears at a threshold of 18 mm Hg of pulmonary artery occlusion pressure, providing a direct biomarker of clinical volemia. The FALLS-protocol sequentially rules out obstructive, then cardiogenic, then hypovolemic shock for expediting the diagnosis of distributive (usually septic) shock. These applications can be done using simple grayscale machines and one microconvex probe suitable for the whole body. Lung ultrasound is a multifaceted tool also useful for decreasing radiation doses (of interest in neonates where the lung signatures are similar to those in adults), from ARDS to trauma management, and from ICUs to points of care. If done in suitable centers, training is the least of the limitations for making use of this kind of visual medicine.

PMID 26033127  Chest. 2015 Jun;147(6):1659-70. doi: 10.1378/chest.14-1・・・
著者: Sundeep R Bhat, David A Johnson, Jessica E Pierog, Brita E Zaia, Sarah R Williams, Laleh Gharahbaghian
雑誌名: West J Emerg Med. 2015 Jul;16(4):503-9. doi: 10.5811/westjem.2015.5.25414. Epub 2015 Jul 14.
Abstract/Text INTRODUCTION: In the United States, there are limited studies regarding use of prehospital ultrasound (US) by emergency medical service (EMS) providers. Field diagnosis of life-threatening conditions using US could be of great utility. This study assesses the ability of EMS providers and students to accurately interpret heart and lung US images.
METHODS: We tested certified emergency medical technicians (EMT-B) and paramedics (EMT-P) as well as EMT-B and EMT-P students enrolled in prehospital training programs within two California counties. Participants completed a pre-test of sonographic imaging of normal findings and three pathologic findings: pericardial effusion, pneumothorax, and cardiac standstill. A focused one-hour lecture on emergency US imaging followed. Post-tests were given to all EMS providers immediately following the lecture and to a subgroup one week later.
RESULTS: We enrolled 57 prehospital providers (19 EMT-B students, 16 EMT-P students, 18 certified EMT-B, and 4 certified EMT-P). The mean pre-test score was 65.2%±12.7% with mean immediate post-test score of 91.1%±7.9% (95% CI [22%-30%], p<0.001). Scores significantly improved for all three pathologic findings. Nineteen subjects took the one-week post-test. Their mean score remained significantly higher: pre-test 65.8%±10.7%; immediate post-test 90.5%±7.0% (95% CI [19%-31%], p<0.001), one-week post-test 93.1%±8.3% (95% CI [21%-34%], p<0.001).
CONCLUSION: Using a small sample of EMS providers and students, this study shows the potential feasibility for educating prehospital providers to accurately identify images of pericardial effusion, pneumothorax, and cardiac standstill after a focused lecture.

PMID 26265961  West J Emerg Med. 2015 Jul;16(4):503-9. doi: 10.5811/we・・・
著者: Eric J Chin, Connie H Chan, Rod Mortazavi, Craig L Anderson, Christopher A Kahn, Shane Summers, J Christian Fox
雑誌名: J Emerg Med. 2013 Jan;44(1):142-9. doi: 10.1016/j.jemermed.2012.02.032. Epub 2012 May 16.
Abstract/Text BACKGROUND: Prehospital ultrasound has been shown to aid in the diagnosis of multiple conditions that do not generally change prehospital management. On the other hand, the diagnoses of cardiac tamponade, tension pneumothorax, or cardiac standstill may directly impact patient resuscitation in the field.
STUDY OBJECTIVE: To determine if prehospital care providers can learn to acquire and recognize ultrasound images for several life-threatening conditions using the Prehospital Assessment with UltraSound for Emergencies (PAUSE) protocol.
METHODS: This is a prospective, educational intervention pilot study at an urban fire department with integrated emergency medical services (EMS). We enrolled 20 emergency medical technicians--paramedic with no prior ultrasonography training. Subjects underwent a 2-h training session on basic ultrasonography of the lungs and heart to evaluate for pneumothorax, pericardial effusion, and cardiac activity. Subjects were tested on image interpretation as well as image acquisition skills. Two bedside ultrasound-trained emergency physicians scored images for adequacy. Image interpretation testing was performed using pre-obtained ultrasound clips containing normal and abnormal images.
RESULTS: All subjects appropriately identified the pleural line, and 19 of 20 paramedics achieved a Cardiac Ultrasound Structural Assessment Scale score of ≥4. For the image interpretation phase, the mean PAUSE protocol video test score was 9.1 out of a possible 10 (95% confidence interval 8.6-9.6).
CONCLUSION: Paramedics were able to perform the PAUSE protocol and recognize the presence of pneumothorax, pericardial effusion, and cardiac standstill. The PAUSE protocol may potentially be useful in rapidly detecting specific life-threatening pathology in the prehospital environment, and warrants further study in existing EMS systems.

Copyright © 2013. Published by Elsevier Inc.
PMID 22595631  J Emerg Med. 2013 Jan;44(1):142-9. doi: 10.1016/j.jemer・・・
著者: G Volpicelli, A Lamorte, M Tullio, L Cardinale, M Giraudo, V Stefanone, E Boero, P Nazerian, R Pozzi, M F Frascisco
雑誌名: Intensive Care Med. 2013 Jul;39(7):1290-8. doi: 10.1007/s00134-013-2919-7. Epub 2013 Apr 13.
Abstract/Text PURPOSE: We analyzed the efficacy of a point-of-care ultrasonographic protocol, based on a focused multiorgan examination, for the diagnostic process of symptomatic, non-traumatic hypotensive patients in the emergency department.
METHODS: We prospectively enrolled 108 adult patients complaining of non-traumatic symptomatic hypotension of uncertain etiology. Patients received immediate point-of-care ultrasonography to determine cardiac function and right/left ventricle diameter rate, inferior vena cava diameter and collapsibility, pulmonary congestion, consolidations and sliding, abdominal free fluid and aortic aneurysm, and leg vein thrombosis. The organ-oriented diagnoses were combined to formulate an ultrasonographic hypothesis of the cause of hemodynamic instability. The ultrasonographic diagnosis was then compared with a final clinical diagnosis obtained by agreement of three independent expert physicians who performed a retrospective hospital chart review of each case.
RESULTS: Considering the whole population, concordance between the point-of-care ultrasonography diagnosis and the final clinical diagnosis was interpreted as good, with Cohen's k = 0.710 (95 % CI, 0.614-0.806), p < 0.0001 and raw agreement (Ra) = 0.768. By eliminating the 13 cases where the final clinical diagnosis was not agreed upon (indefinite), the concordance increased to almost perfect, with k = 0.971 (95 % CI, 0.932-1.000), p < 0.0001 and Ra = 0.978.
CONCLUSIONS: Emergency diagnostic judgments guided by point-of-care multiorgan ultrasonography in patients presenting with undifferentiated hypotension significantly agreed with a final clinical diagnosis obtained by retrospective chart review. The integration of an ultrasonographic multiorgan protocol in the diagnostic process of undifferentiated hypotension has great potential in guiding the first-line therapeutic approach.

PMID 23584471  Intensive Care Med. 2013 Jul;39(7):1290-8. doi: 10.1007・・・
著者: Roberto Copetti, Paolo Copetti, Angelika Reissig
雑誌名: Ultrasound Med Biol. 2012 Mar;38(3):349-59. doi: 10.1016/j.ultrasmedbio.2011.11.015. Epub 2012 Jan 21.
Abstract/Text A rapid identification of the causes of hemodynamic instability or cardiac arrest is crucial for correct treatment. In a critical care setting, ultrasound seems to be an ideal tool for a rapid diagnosis. A multiple-goal problem-based approach represents the main peculiarity of emergency ultrasound and may be considered an extension of physical examination. The integration of data that can rapidly be obtained from the heart, lung, inferior vena cava, abdomen and leg vein examination are often essential for the diagnosis and treatment in critically ill patients. The role and potentiality of integrated ultrasound in cardiac arrest, shock/hypotension and severe dyspnea are considered in this article.

Copyright © 2012 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.
PMID 22266231  Ultrasound Med Biol. 2012 Mar;38(3):349-59. doi: 10.101・・・
著者: Maxine Inocencio, Jeannine Childs, Mikaela L Chilstrom, Kristin Berona
雑誌名: J Emerg Med. 2017 Jun;52(6):e217-e220. doi: 10.1016/j.jemermed.2017.02.008. Epub 2017 Mar 23.
Abstract/Text BACKGROUND: Delayed recognition of tension pneumothorax can lead to a mortality of 31% to 91%. However, the classic physical examination findings of tracheal deviation and distended neck veins are poorly sensitive in the diagnosis of tension pneumothorax. Point-of-care ultrasound is accurate in identifying the presence of pneumothorax, but sonographic findings of tension pneumothorax are less well described.
CASE REPORT: We report the case of a 21-year-old man with sudden-onset left-sided chest pain. He was clinically stable without hypoxia or hypotension, and the initial chest x-ray study showed a large pneumothorax without mediastinal shift. While the patient was awaiting tube thoracostomy, a point-of-care ultrasound demonstrated findings of mediastinal shift and a dilated inferior vena cava (IVC) concerning for tension physiology, even though the patient remained hemodynamically stable. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case demonstrates a unique clinical scenario of ultrasound evidence of tension physiology in a clinically stable patient. Although this patient was well appearing without hypotension, respiratory distress, tracheal deviation, or distended neck veins, point-of-care ultrasound revealed mediastinal shift and a plethoric IVC. Given that the classic clinical signs of tension pneumothorax are not uniformly present, this case shows how point-of-care ultrasound may diagnose tension pneumothorax before clinical decompensation.

Published by Elsevier Inc.
PMID 28342574  J Emerg Med. 2017 Jun;52(6):e217-e220. doi: 10.1016/j.j・・・
著者: Sean Clark, Michael Ragg, Julian Stella
雑誌名: Emerg Med (Fremantle). 2003 Oct-Dec;15(5-6):429-33.
Abstract/Text OBJECTIVE: To determine the incidence of mediastinal shift on chest X-ray due to pneumothorax.
METHODS: A retrospective chart review was undertaken of all patients with pneumothorax presenting to the ED over the period 1 January 1995 to 31 December 1999. The primary outcome was mediastinal shift on initial CXR. The incidence of clinical tension pneumothorax was noted.
RESULTS: There were 176 presentations with pneumothorax in the study period. Two cases of clinical tension pneumothorax were identified and treated prior to CXR. Thirty patients with mediastinal shift on initial CXR, none of which clinically merited emergency needle decompression, were all managed with intercostal catheter (ICC) insertion. Overall, 141 of 176 (80.1%) had an ICC inserted as part of their management. Mean pulse rate (91.8 SD 29.5 vs 86.7 SD 23.6, P = 0.02) and respiratory rate (21.9 SD 14.4 vs 15.1 SD 11.5, P = 0.03) were greater in patients with mediastinal shift on CXR.
CONCLUSION: True clinical tension pneumothorax is an uncommon condition. Radiological evidence of mediastinal shift is more common. No patient in this latter group deteriorated while awaiting X-ray.

PMID 14992056  Emerg Med (Fremantle). 2003 Oct-Dec;15(5-6):429-33.
著者: Imme Zengerink, Peter R Brink, Kevin B Laupland, Earl L Raber, Dave Zygun, John B Kortbeek
雑誌名: J Trauma. 2008 Jan;64(1):111-4. doi: 10.1097/01.ta.0000239241.59283.03.
Abstract/Text BACKGROUND: A tension pneumothorax requires immediate decompression using a needle thoracostomy. According to advanced trauma life support guidelines this procedure is performed in the second intercostal space (ICS) in the midclavicular line (MCL), using a 4.5-cm (2-inch) catheter (5-cm needle). Previous studies have shown a failure rate of up to 40% using this technique. Case reports have suggested that this high failure rate could be because of insufficient length of the needle.
OBJECTIVES: To analyze the average chest wall thickness (CWT) at the second ICS in the MCL in a trauma population and to evaluate the length of the needle used in needle thoracostomy for emergency decompression of tension pneumothoraces.
METHODS: Retrospective review of major trauma admissions (Injury Severity Score >12) at the Foothills Medical Centre in Calgary, Canada, who underwent a computed tomography chest scan admitted in the period from October 2001 until March 2004. Subgroup analysis on men and women, <40 years of age and >/=40 years of age was defined a priori. CWT was measured to the nearest 0.01 cm at the second ICS in the MCL.
RESULTS: The mean CWT in the 604 male patients and 170 female patients studied averaged 3.50 cm at the left second ICS MCL and 3.51 cm on the right. The mean CWT was significantly higher for women than men (p < 0.0001). About 9.9% to 19.3% of the men had a CWT >4.5 cm and 24.1% to 35.4% of the women studied.
CONCLUSIONS: A catheter length of 4.5 cm may not penetrate the chest wall of a substantial amount (9.9%-35.4%) of the population, depending on age and gender. This study demonstrates the need for a variable needle length for relief of a tension pneumothorax in certain population groups to improve effectiveness of needle thoracostomy.

PMID 18188107  J Trauma. 2008 Jan;64(1):111-4. doi: 10.1097/01.ta.0000・・・
著者: Shahriar Zehtabchi, Claritza L Rios
雑誌名: Ann Emerg Med. 2008 Jan;51(1):91-100, 100.e1. doi: 10.1016/j.annemergmed.2007.06.009. Epub 2007 Sep 29.
Abstract/Text STUDY OBJECTIVE: The emergency management of primary spontaneous pneumothorax is controversial. This evidence-based emergency medicine review evaluates the existing evidence about the efficacy and safety of needle aspiration in comparison to tube thoracostomy for management of primary spontaneous pneumothorax.
METHODS: We searched MEDLINE, EMBASE, the Cochrane Library, and other databases. We selected studies for inclusion in the review if the authors stated that they had randomly assigned hemodynamically stable patients with no underlying lung disease to needle aspiration or tube thoracostomy. The outcome measures of interest included admission rate, length of hospital stay, recurrence rate, failure rate of the procedure, dyspnea score during or after the procedure, pain score during or after the procedure, and complications.
RESULTS: Three randomized trials with acceptable quality standards met the inclusion criteria. There was no significant difference between needle aspiration and tube thoracostomy when outcomes of immediate failure, 1-week failure, risk of complication, and 1-year recurrence rate were measured. Only 2 trials reported the rate of hospitalization; needle aspiration was associated with lower rates of hospitalization in both trials: relative risks of 0.26 (95% confidence interval [CI] 0.17 to 0.39) and 0.51 (95% CI 0.36 to 0.74). Length of hospital stay was lower in the needle aspiration groups in all 3 trials, with mean differences of -2.15 days (95% CI -0.99 to -3.30), -2.10 days (95% CI -0.57 to -3.63), and -1.10 days (95% CI -2.28 to 0.08), respectively. Needle aspiration was associated with less analgesia requirement in one trial and lower pain scores in another.
CONCLUSION: The existing evidence indicates that needle aspiration is at least as safe and effective as tube thoracostomy for management of primary spontaneous pneumothorax. Additionally, needle aspiration carries the benefit of fewer hospital admissions and shorter length of hospital stay.

PMID 18166436  Ann Emerg Med. 2008 Jan;51(1):91-100, 100.e1. doi: 10.1・・・
著者: A Robb McLean, Michael E Richards, Cameron S Crandall, Jonathan L Marinaro
雑誌名: Am J Emerg Med. 2011 Nov;29(9):1173-7. doi: 10.1016/j.ajem.2010.06.030. Epub 2010 Oct 13.
Abstract/Text OBJECTIVE: Computed tomography measurements of chest wall thickness (CWT) suggest that standard-length angiocatheters (4.5 cm) may fail to decompress tension pneumothoraces. We used an alternative modality, ultrasound, to measure CWT. We correlated CWT with body mass index (BMI) and used national data to estimate the percentage of patients with CWT greater than 4.5 cm.
METHODS: This was an observational, cross-sectional study of a convenience sample. We recorded standing height, weight, and sex. We measured CWT with ultrasound at the second intercostal space, midclavicular line and at the fourth intercostal space, midaxillary line on supine subjects. We correlated BMI (weight [in kilograms]/height(2) [in square meters]) with CWT using linear regression. 95% Confidence intervals (CIs) assessed statistical significance. National Health and Nutrition Examination Survey results for 2007-2008 were combined to estimate national BMI adult measurements.
RESULTS: Of 51 subjects, 33 (65%) were male and 18 (35%) were female. Mean anterior CWT (male, 2.1 cm; CI, 1.9-2.3; female, 2.3 cm; CI, 1.7-2.7), lateral CWT (male, 2.4 cm; CI, 2.1-2.6; female, 2.5 cm; CI 2.0-2.9), and BMI (male, 27.7; CI, 26.1-29.3; female, 30.0; CI, 25.8-34.2) did not differ by sex. Lateral CWT was greater than anterior CWT (0.2 cm; CI, 0.1-0.4; P < .01). Only one subject with a BMI of 48.2 had a CWT that exceeded 4.5 cm. Using national BMI estimates, less than 1% of the US population would be expected to have CWT greater than 4.5 cm.
CONCLUSIONS: Ultrasound measurements suggest that most patients will have CWT less than 4.5 cm and that CWT may not be the source of the high failure rate of needle decompression in tension pneumothorax.

Copyright © 2011 Elsevier Inc. All rights reserved.
PMID 20947279  Am J Emerg Med. 2011 Nov;29(9):1173-7. doi: 10.1016/j.a・・・
著者: Chad G Ball, Amy D Wyrzykowski, Andrew W Kirkpatrick, Christopher J Dente, Jeffrey M Nicholas, Jeffrey P Salomone, Grace S Rozycki, John B Kortbeek, David V Feliciano
雑誌名: Can J Surg. 2010 Jun;53(3):184-8.
Abstract/Text BACKGROUND: Tension pneumothorax requires emergent decompression. Unfortunately, some needle thoracostomies (NTs) are unsuccessful because of insufficient catheter length. All previous studies have used thickness of the chest wall (based on cadaver studies, ultrasonography or computed tomography [CT]) to extrapolate probable catheter effectiveness. The objective of this clinical study was to identify the frequency of NT failure with various catheter lengths.
METHODS: We evaluated the records of all patients with severe blunt injury who had a prehospital NT before arrival at a level-1 trauma centre over a 48-month period. Patients were divided into 2 groups: helicopter (4.5-cm catheter sheath) and ground ambulance (3.2 cm) transport. Success of the NT was confirmed by the absence of a large pneumothorax on subsequent thoracic ultrasonography and CT.
RESULTS: Needle thoracostomy decompression was attempted in 1.5% (142/9689) of patients. Among patients with blunt injuries, the incidence was 1.4% (101/7073). Patients transported by helicopter (74%) received a 4.5-cm sheath. The remainder (26% ground transport) received a 3.2-cm catheter. A minority in each group (helicopter 15%, ground 28%) underwent immediate chest tube insertion (before thoracic ultrasound) because of ongoing hemodynamic instability. Failure to decompress the pleural space by NT was observed via ultrasound and/or CT in 65% (17/26) of attempts with a 3.2-cm catheter, compared with only 4% (3/75) of attempts with a 4.5-cm catheter (p < 0.001).
CONCLUSION: Tension pneumothorax decompression using a 3.2-cm catheter was unsuccessful in up to 65% of cases. When a larger 4.5-cm catheter was used, fewer procedures (4%) failed. Thoracic ultrasonography can be used to confirm NT placement.

PMID 20507791  Can J Surg. 2010 Jun;53(3):184-8.
著者: Takeshi Yamagiwa, Seiji Morita, Rie Yamamoto, Tomoko Seki, Katsuhiko Sugimoto, Sadaki Inokuchi
雑誌名: Injury. 2012 Jan;43(1):42-5. doi: 10.1016/j.injury.2010.11.022. Epub 2010 Dec 24.
Abstract/Text BACKGROUND: Previous studies reported a high failure rate in relieving tension pneumothorax by needle thoracostomy, because the catheter was not sufficiently long to access the pleural space. The Advanced Trauma Life Support guideline recommends needle thoracostomy at the second intercostal space in the middle clavicular line using a 5.0-cm catheter, whereas the corresponding guideline in Japan does not mention a catheter length. It is necessary to measure the chest wall thickness (CWT) and determine the appropriate catheter length taking the differences of habitus in race and region into consideration. This study was designed to analyse CWT in Japanese trauma patients by computed tomography and to determine the percentage of patients whose pleural space would be accessible using a 5.0-cm catheter.
PATIENTS AND METHODS: We performed a retrospective review of chest computed tomography of 256 adult Japanese trauma patients who were admitted to the level 1 trauma centre of Tokai University Hospital in Kanagawa, Japan between January and July 2008. In 256 patients, the CWT at 512 sites (left and right sides) was measured by chest computed tomography at the second intercostal space in the middle clavicular line. The frequency of measurement sites <5.0 cm was calculated simultaneously. The samples were divided according to gender, side (left and right), abbreviated injury scale (<3, ≧3), arm position during examination (up/down), and the existence or non-existence of associated injuries (pneumothorax, subcutaneous emphysema, and fracture of the sternum and ribs); the CWT of each group was compared.
RESULTS: The mean CWT measured in 192 males and 64 females was 3.06±1.02 cm. The CWT values at 483 sites (94.3%) were less than 5.0 cm. The CWT of females was significantly greater than that of males (3.66 cm vs. 2.85 cm, p<0.0001), and patients with subcutaneous emphysema had greater CWTs than those without it (4.16 cm vs. 3.01 cm, p<0.0001).
CONCLUSION: The mean CWT at the second intercostal space in the middle clavicular line was 3.06 cm. It is likely that over 94% of Japanese trauma patients could be treated with a 5.0-cm catheter.

Copyright © 2010 Elsevier Ltd. All rights reserved.
PMID 21185558  Injury. 2012 Jan;43(1):42-5. doi: 10.1016/j.injury.2010・・・
著者: D Laws, E Neville, J Duffy, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society
雑誌名: Thorax. 2003 May;58 Suppl 2:ii53-9.
Abstract/Text
PMID 12728150  Thorax. 2003 May;58 Suppl 2:ii53-9.
著者: Kenji Inaba, Efstathios Karamanos, Dimitra Skiada, Daniel Grabo, Peter Hammer, Matthew Martin, Maura Sullivan, Marc Eckstein, Demetrios Demetriades
雑誌名: J Trauma Acute Care Surg. 2015 Dec;79(6):1044-8. doi: 10.1097/TA.0000000000000849.
Abstract/Text BACKGROUND: Computed tomographic and cadaveric studies have demonstrated needle decompression of tension pneumothorax at the fifth intercostal space (ICS), anterior axillary line (AAL) has advantages over the second ICS midclavicular line (MCL). The purpose of this study was to compare the ability of prehospital care providers to accurately decompress the chest at these two locations.
METHODS: Randomly selected US Navy hospital corpsmen (n = 25) underwent a standardized training session followed by timed needle decompression on unmarked fresh cadavers. A 14-gauge angiocatheter was inserted in the right and left second ICS MCL and fifth ICS AAL in a predetermined computer-generated order. Time from needle uncapping to insertion, accuracy, and ease of placement were examined.
RESULTS: A total of 25 corpsmen inserted 100 needles into 25 cadavers. Mean (SD) age was 25.9 (3.7) years, 72.0% were male, with 4.2 (3.2) years of experience, and 52.0% had previously deployed. A total of 60.0% had attempted decompression previously, 93.3% in a model and 6.7% in a patient. Time to decompression did not differ between the second and fifth ICS (16.8 [10.1] seconds vs. 16.9 [12.3] seconds, p = 0.438). Accuracy however was superior at the fifth ICS, with a misplacement rate of only 22.0% versus 82.0% at the second ICS (p < 0.001). The aggregate distance from the target position was also significantly greater for the second ICS (3.1 [1.7] cm vs. 1.2 [1.5] cm, p < 0.001). Insertion at the fifth ICS was rated as being easier than the second by 76.0% of providers, the same by 12.0%, and more difficult by 12.0%.
CONCLUSION: For prehospital care providers, the fifth ICS AAL can be localized and decompressed with a higher degree of accuracy than the traditional second ICS MCL. It is rated as easier to perform and can be done just as quickly. Based on these data, the fifth ICS AAL should be considered as an equivalent first-line position for needle decompression in patients with clinical evidence of a tension pneumothorax.

PMID 26488319  J Trauma Acute Care Surg. 2015 Dec;79(6):1044-8. doi: 1・・・
著者: Kenji Inaba, Bernardino C Branco, Marc Eckstein, David V Shatz, Matthew J Martin, Donald J Green, Thomas T Noguchi, Demetrios Demetriades
雑誌名: J Trauma. 2011 Nov;71(5):1099-103; discussion 1103. doi: 10.1097/TA.0b013e31822d9618.
Abstract/Text BACKGROUND: Needle thoracostomy is an emergent procedure designed to relieve tension pneumothorax. High failure rates because of the needle not penetrating into the thoracic cavity have been reported. Advanced Trauma Life Support guidelines recommend placement in the second intercostal space, midclavicular line using a 5-cm needle. The purpose of this study was to evaluate placement in the fifth intercostal space, midaxillary line, where tube thoracostomy is routinely performed. We hypothesized that this would result in a higher successful placement rate.
METHODS: Twenty randomly selected unpreserved adult cadavers were evaluated. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. The needles were secured and thoracotomy was then performed to assess penetration into the pleural cavity. The right and left sides were analyzed separately acting as their own controls for a total of 80 needles inserted into 20 cadavers. The thickness of the chest wall at the site of penetration was then measured for each entry position.
RESULTS: A total of 14 male and 6 female cadavers were studied. Overall, 100% (40 of 40) of needles placed in the fifth intercostal space and 57.5% (23 of 40) of the needles placed in the second intercostal space entered the chest cavity (p < 0.001); right chest: 100% versus 60.0% (p = 0.003) and left chest: 100% versus 55.0% (p = 0.001). Overall, the thickness of the chest wall was 3.5 cm ± 0.9 cm at the fifth intercostal space and 4.5 cm ± 1.1 cm at the second intercostal space (p < 0.001). Both right and left chest wall thicknesses were similar (right, 3.6 cm ± 1.0 cm vs. 4.5 cm ± 1.1 cm, p = 0.007; left, 3.5 ± 0.9 cm vs. 4.4 cm ± 1.1 cm, p = 0.008).
CONCLUSIONS: In a cadaveric model, needle thoracostomy was successfully placed in 100% of attempts at the fifth intercostal space but in only 58% at the traditional second intercostal position. On average, the chest wall was 1 cm thinner at this position and may improve successful needle placement. Live patient validation of these results is warranted.

PMID 22071914  J Trauma. 2011 Nov;71(5):1099-103; discussion 1103. doi・・・
著者: Kenji Inaba, Crystal Ives, Kelsey McClure, Bernardino C Branco, Marc Eckstein, David Shatz, Matthew J Martin, Sravanthi Reddy, Demetrios Demetriades
雑誌名: Arch Surg. 2012 Sep;147(9):813-8. doi: 10.1001/archsurg.2012.751.
Abstract/Text OBJECTIVE: To compare the distance to be traversed during needle thoracostomy decompression performed at the second intercostal space (ICS) in the midclavicular line (MCL) with the fifth ICS in the anterior axillary line (AAL).
DESIGN: Patients were separated into body mass index (BMI) quartiles, with BMI calculated as weight in kilograms divided by height in meters squared. From each BMI quartile, 30 patients were randomly chosen for inclusion in the study on the basis of a priori power analysis (n = 120). Chest wall thickness on computed tomography at the second ICS in the MCL was compared with the fifth ICS in the AAL on both the right and left sides through all BMI quartiles.
SETTING: Level I trauma center.
PATIENTS: Injured patients aged 16 years or older evaluated from January 1, 2009, to January 1, 2010, undergoing computed tomography of the chest.
RESULTS: A total of 680 patients met the study inclusion criteria (81.5% were male and mean age was 41 years [range, 16-97 years]). Of the injuries sustained, 13.2% were penetrating, mean (SD) Injury Severity Score was 15.5 (10.3), and mean BMI was 27.9 (5.9) (range, 15.4-60.7). The mean difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL was 12.9 mm (95% CI, 11.0-14.8; P < .001) on the right and 13.4 mm (95% CI, 11.4-15.3; P < .001) on the left. There was a stepwise increase in chest wall thickness across all BMI quartiles at each location of measurement. There was a significant difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL in all quartiles on both the right and the left. The percentage of patients with chest wall thickness greater than the standard 5-cm decompression needle was 42.5% at the second ICS in the MCL and only 16.7% at the fifth ICS in the AAL.
CONCLUSIONS: In this computed tomography-based analysis of chest wall thickness, needle thoracostomy decompression would be expected to fail in 42.5% of cases at the second ICS in the MCL compared with 16.7% at the fifth ICS in the AAL. The chest wall thickness at the fifth ICS AAL was 1.3 cm thinner on average and may be a preferred location for needle thoracostomy decompression.

PMID 22987168  Arch Surg. 2012 Sep;147(9):813-8. doi: 10.1001/archsurg・・・
著者: Danuel V Laan, Trang Diem N Vu, Cornelius A Thiels, T K Pandian, Henry J Schiller, M Hassan Murad, Johnathon M Aho
雑誌名: Injury. 2016 Apr;47(4):797-804. doi: 10.1016/j.injury.2015.11.045. Epub 2015 Dec 13.
Abstract/Text INTRODUCTION: Current Advanced Trauma Life Support guidelines recommend decompression for thoracic tension physiology using a 5-cm angiocatheter at the second intercostal space (ICS) on the midclavicular line (MCL). High failure rates occur. Through systematic review and meta-analysis, we aimed to determine the chest wall thickness (CWT) of the 2nd ICS-MCL, the 4th/5th ICS at the anterior axillary line (AAL), the 4th/5th ICS mid axillary line (MAL) and needle thoracostomy failure rates using the currently recommended 5-cm angiocatheter.
METHODS: A comprehensive search of several databases from their inception to July 24, 2014 was conducted. The search was limited to the English language, and all study populations were included. Studies were appraised by two independent reviewers according to a priori defined PRISMA inclusion and exclusion criteria. Continuous outcomes (CWT) were evaluated using weighted mean difference and binary outcomes (failure with 5-cm needle) were assessed using incidence rate. Outcomes were pooled using the random-effects model.
RESULTS: The search resulted in 34,652 studies of which 15 were included for CWT analysis, 13 for NT effectiveness. Mean CWT was 42.79 mm (95% CI, 38.78-46.81) at 2nd ICS-MCL, 39.85 mm (95% CI, 28.70-51.00) at MAL, and 34.33 mm (95% CI, 28.20-40.47) at AAL (P=.08). Mean failure rate was 38% (95% CI, 24-54) at 2nd ICS-MCL, 31% (95% CI, 10-64) at MAL, and 13% (95% CI, 8-22) at AAL (P=.01).
CONCLUSION: Evidence from observational studies suggests that the 4th/5th ICS-AAL has the lowest predicted failure rate of needle decompression in multiple populations.
LEVEL OF EVIDENCE: Level 3 SR/MA with up to two negative criteria.
STUDY TYPE: Therapeutic.

Copyright © 2015 Elsevier Ltd. All rights reserved.
PMID 26724173  Injury. 2016 Apr;47(4):797-804. doi: 10.1016/j.injury.2・・・
著者: S Goh, W R Xu, L T Teo
雑誌名: Eur J Trauma Emerg Surg. 2018 Oct;44(5):767-771. doi: 10.1007/s00068-017-0853-z. Epub 2017 Oct 3.
Abstract/Text INTRODUCTION: Our study aims to compare the anterior and lateral approaches for needle thoracostomy (NT) and determine the adequacy of catheter lengths used for NT in Asian trauma patients based on computed tomography chest wall measurements.
METHODOLOGY: A retrospective review of chest computed tomography scans of 583 Singaporean trauma patients during period of 2011-2015 was conducted. Four measurements of chest wall thickness (CWT) were taken at the second intercostal space, midclavicular line and fifth intercostal space, midaxillary line bilaterally. Measurements were from the superficial skin layer of the chest wall to the pleural space. Successful NT was defined radiologically as CWT ≤ 5 cm.
RESULTS: There were 593 eligible subjects. Mean age was 49.1 years (49.1 ± 21.0). Majority were males (77.0%) and Chinese (70.2%). Mean CWT for the anterior approach was 4.04 cm (CI 3.19-4.68) on the left and 3.92 cm (CI 3.17-4.63) on the right. Mean CWT for the lateral approach was 3.52 cm (CI 2.52-4.36) on the left, and 3.62 cm (CI 3.65-4.48) on the right. Mean CWT was shorter in the lateral approach by 0.52 cm on the left and 0.30 cm on the right (p = 0.001). With a 5.0 cm catheter in the anterior approach, 925 out of 1186 sites (78.8%) will have adequate NT as compared to 98.2% with a 7.0 cm catheter. Similarly, in the lateral approach 1046 out of 1186 (88.2%) will have adequate NT as compared to 98.5% with a 7.0 cm catheter. Obese subjects had significantly higher mean CWT in both approaches (p = 0.001). There was moderate correlation between BMI and CWT in the anterior approach, r 2 = 0.529 as compared to the lateral approach, r 2 = 0.244.
CONCLUSION: Needle decompression using the lateral approach or a longer catheter is more likely to succeed in Asian trauma patients. A high BMI is an independent predictor of failure of NT, especially for the anterior as compared to lateral approach.

PMID 28975363  Eur J Trauma Emerg Surg. 2018 Oct;44(5):767-771. doi: 1・・・

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