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Pneumothorax aspiration (needle thoracocentesis)


Indications for pneumothorax aspiration (needle thoracocentesis)

  • Primary spontaneous pneumothorax greater than 2cm (at level of hilum) +/- breathlessness
  • Primary spontaneous pneumothorax under 2cm but symptomatic
    • BTS guidelines advise 2 attempts at aspiration can occur
    • If the primary pneumothorax is less than 2cm and the patient is asymptomatic re-image in 2-3 weeks
  • Tension pneumothorax


Equipment required for pneumothorax aspiration (needle thoracocentesis)

  • Sterile field
    • Sterile dressing pack and gloves
    • 2% Chlorhexadine swabs
  • Analgesia
    • 4mls of 1% or 2% Lidocaine
    • Orange (25G) needle (x1)
    • Green (19G) needle (x1)
    • 5ml Syringe (x1)
  • 16-18 gauge cannula
  • 3-way tap
  • 50 ml syringe


 Contraindications to pneumothorax aspiration (needle thoracocentesis)

  • Severe coagulopathy
  • Pneumothorax less than 2cm and asymptomatic
  • Secondary pneumothorax
  • Local infection



  • Gain consent from the patient – ideally consent should be written
    • Consent for pain, failure of procedure, bleeding, infection, damage to surrounding structures
  • Familiarise yourself with the landmarks
    • 2nd intercostal space in the midclavicular line (above rib to avoid neurovascular bundle on posterior aspect of second rib)
    • Mark area if necessary
    • Set up a sterile trolley with equipment


Location of intercostal structures (note diagram shows effusion, not pneumothorax)


 Procedure for pneumothorax aspiration (needle thoracocentesis)

  • Don sterile gloves and clean area with chlorhexidine
  • Apply sterile field
  • Insert lignocaine 5-10ml initially under the skin and then into subcutaneous tissues and pleural space.
    • Air should be aspirated with green needle and local anaesthetic
  • Take cannula and insert at 90 degrees in second intercostal space, midclavicular line
    • Begin to remove needle once at the depth air was aspirated with the green needle but advance plastic sheath to the hilt. Be cautious not to kink the cannula
  • Attach three way tap to cannula and then syringe to three way tap
  • Aspirate air via three way tap, ensuring tap is closed whenever the syringe is removed so no air is allowed into the chest.
  • Aim to aspirate until resistance
    • Usually this is less than 2.5L
  • Remove cannula
  • Apply dressing


Video on pneumothorax aspiration


 Post-procedure care

  • Analgesia
  • Chest X-ray
  • If pneumothorax remains greater than 2cm, proceed to a further attempt at aspiration
    • If second attempt fails to resolve pneumothorax, seek senior respiratory review with a view to chest drain insertion
  • If pneumothorax remains but is less than 2 cm and the patient’s symptoms have improved they can be discharged with future follow up arranged
    • The respiratory team are usually happy to see these patients but it is your responsibility to arrange this
  • Patients who have suffered a pneumothorax must be advised that they can never do diving (due to pressure changes) and that they cannot fly for at least two weeks after full resolution of the pneumothorax
    • The diving rule can only be overturned if the patient undergoes chemical pleurodesis
  • Advise patients who smoke to stop
    • Smokers have an increased risk of recurrence


 In the event of failure of thoracocentesis

  • Stop procedure
  • Seek senior help
  • Repeat chest x-ray and review clinically


 Top tips for pneumothorax aspiration (thoracocentesis)

  • If discharging a patient with a residual pneumothorax ensure they are aware of this and that they know they should re-attend hospital at any time if their symptoms return or they feel unwell.
  • Patients being discharged with a residual pneumothorax MUST have a follow up x-ray arranged to confirm resolution of the pneumothorax at a later date.
    • Follow up x-ray can be performed 1-2 weeks later


Click here to download free teaching notes on pneumothorax aspiration: Procedures – Pneumothorax aspiration

Perfect revision for medical students, finals, OSCEs and MRCP PACES