title: Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy.
abstract: BACKGROUND
  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).
  
  
  CONCLUSIONS
  Evidence from observational studies suggests that the 4th/5th ICS-AAL has the lowest predicted failure rate of needle decompression in multiple populations.
  
  
  METHODS
  Level 3 SR/MA with up to two negative criteria.
  
  
  METHODS
  Therapeutic.
authors.affiliation: Department of General Surgery, Mayo Clinic College of Medicine, Rochester, MN, United States. Electronic address: Laan.Danuel@mayo.edu.
authors.forename: Danuel V
authors.initials: DV
authors.lastname: Laan
authors.affiliation: Mayo Clinic, Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN, United States. Electronic address: Vu.TrangNDiem@mayo.edu.
authors.forename: Trang Diem N
authors.initials: TD
authors.lastname: Vu
authors.affiliation: Department of General Surgery, Mayo Clinic College of Medicine, Rochester, MN, United States. Electronic address: Thiels.Cornelius@mayo.edu.
authors.forename: Cornelius A
authors.initials: CA
authors.lastname: Thiels
authors.affiliation: Department of General Surgery, Mayo Clinic College of Medicine, Rochester, MN, United States. Electronic address: pandian.twinkle@mayo.edu.
authors.forename: T K
authors.initials: TK
authors.lastname: Pandian
authors.affiliation: Division of Trauma, Critical Care, and General Surgery, Mayo Clinic College of Medicine, Rochester, MN, United States. Electronic address: Schiller.Henry@mayo.edu.
authors.forename: Henry J
authors.initials: HJ
authors.lastname: Schiller
authors.affiliation: Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States. Electronic address: Murad.Mohammad@mayo.edu.
authors.forename: M Hassan
authors.initials: MH
authors.lastname: Murad
authors.affiliation: Department of General Surgery, Mayo Clinic College of Medicine, Rochester, MN, United States; Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, MN, United States. Electronic address: aho.johnathon@mayo.edu.
authors.forename: Johnathon M
authors.initials: JM
authors.lastname: Aho
mesh_terms: D057785:Catheters / Q000706:statistics & numerical data; D019299:Decompression, Surgical / Q000379:methods*; D006801:Humans; D011030:Pneumothorax / Q000000981:diagnostic imaging* / Q000209:etiology / Q000601:surgery; D017410:Practice Guidelines as Topic; D035441:Thoracic Wall / Q000033:anatomy & histology* / Q000000981:diagnostic imaging; D013907:Thoracostomy / Q000295:instrumentation / Q000379:methods*; D014057:Tomography, X-Ray Computed; D014947:Wounds and Injuries / Q000150:complications*
keywords: Needle decompression; Needle decompression location; Needle thoracostomy; Optimal positioning; Tension pneumothorax