Life-Threatening Collapsed Lung: Survival Better With Prehospital Needle Insertion

For trauma patients who require emergent chest decompression, prehospital needle decompression (PHND) was associated with a lower risk of mortality compared with tube thoracostomy, a cohort study found.

Those receiving PHND within 15 minutes of arriving at the trauma center were 21% less likely to die within 24 hours compared with propensity-matched peers receiving tube thoracostomy without PHND (OR 0.79, 95% CI 0.62-0.98), according to findings published in JAMA Surgery.

The survival advantage of PHND persisted among those who survived their emergency department stay (OR 0.68, 95% CI 0.52-0.89, P<0.01) and when analysis was restricted to patients with severe chest injury (OR 0.72, 95% CI 0.55-0.93, P=0.01), reported Joshua Brown, MD, of University of Pittsburgh Medical Center, and colleagues.

PHND is a potentially life-saving intervention to temporarily treat tension pneumothorax — a life-threatening condition when air is trapped in the pleural space and compromises cardiopulmonary function — but its effectiveness is subject to ongoing debate. Currently, emergency medical services (EMS) clinicians rarely opt for the procedure, Brown and colleagues noted.

Indeed, the investigators found the rate of PHND performed on possibly eligible trauma patients was 11% in the study — less than 1% annually across all trauma patients through the entire study period from 2000 to 2020. EMS accounted for 57% of the variation in PHND rates, and patient factors the remaining 43%.

Study authors acknowledged, however, that tension pneumothorax cannot be confirmed after PHND is performed, making this a challenge of retrospective studies.

Surgeons Hannah Holland, MD, and Daniel Holena, MD, both from the Medical College of Wisconsin in Wauwatosa, advised a more cautious approach to the treatment.

“Since most patients (91% in the current study) who undergo PHND will subsequently undergo tube thoracostomy, a balance must be struck between the benefits of liberal early decompression and the risks of subsequent thoracostomy tube placement, which carries a nearly 40% rate of complications in some studies,” they noted in an accompanying editorial.

Nevertheless, it is still likely that PHND is underused, according to the duo.

Holland and Holena suggested that increasing availability of technology such as handheld ultrasound devices will allow for more optimized care in the prehospital environment. Until then, however, EMS professionals would have to “balance the benefits of early decompression with the subsequent risks associated with tube thoracostomy on a case-by-case basis.”

The retrospective cohort study was conducted using data collected from January 2000 to March 2020 by the Pennsylvania Trauma Outcomes Study. Data from patients older than 15 years of age and who were transported from the scene of injury were analyzed. Patients were excluded if their main cause of injury was a burn or if they were dead on arrival.

Brown and colleagues included 8,469 trauma patients in the study: 1,337 who received PHND (median age 37 years, 82% men) and 7,132 matched peers who had a chest tube placed (median age 32, 85.3% men). The authors said this group likely represented patients with tension pneumothorax who would have benefited from PHND.

Besides this assumption, another major limitation of the observational study was that causation between PHND and 24-hour survival could not be determined, Brown’s group warned, as the reduction in mortality associated PHND may be a proxy for more aggressive prehospital trauma care.

The study’s reliance on ICD coding meant the investigators were also unable to determine on which side or anatomic site a patient received PHND, and they lacked data on field hypoxia or dyspnea.

Nevertheless, the authors recommended that PHND be more widely taught in EMS education and used in appropriate trauma cases.