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888.448.1238 | AironUSA.com pNeuton ™ model S ventilator with CPAP p N e u t o n ™ m o d e l S MACS ™ Stand-alone CPAP pNeuton ™ mini Neonate to pediatric ventilator with nCPAP CPAP + VentilAtion. All in one. With the pNeuton model S you'll be prepared for any emergency respiratory situation. The ventilator has built-in CPAP, provides adult/pediatric volume or bi-level pressure ventilation as well as mask CPAP ventilation. Pure pneumatic technology eliminates batteries. And it's real easy to use. Learn more about Airon's respiratory devices for EMS. Visit AironUSA.com today. Be PrePAred. For Anything. Discover the pNeuton model S ventilator with CPAP. For More Information Circle 26 on Reader Service Card As our population becomes more obese, the distance the needle must traverse becomes longer and the concern that the pleural space is not reached is heightened. The most recent Advanced Trauma Life Support manual recommends "inserting a large-caliber needle into the second intercostal space in the midclavicular line of the affected hemithorax," but also notes that chest wall thickness can affect the chances of successful needle decompression. 6 This was demonstrated as early as 1996 in a case report that noted after successful needle decompression of tension pneumothorax, when the pressure applied to the chest wall to insert the catheter was removed, the natural recoil of the chest wall dislodged the cannula from the pleural space and in essence recreated tension physiology. 2 Another factor prompting consideration of alternative sites is secondary injury sustained from needle insertion. A 2003 case series presented three patients with pneumothoraces who were needle-decompressed in the 2ICS-MCL and eventually developed life-threatening intrathoracic hemorrhages. 13 The author's concern was that this location was in close proximity to the subclavian vessels and internal mammary artery and its medial branches. 13 A separate 2003 case report actually described cardiac tamponade from laceration of the pulmonary artery. 3 Lastly it is important to point out that although a healthcare practitioner may know the proper site, that does not mean they can find it. This unfortunate fact was confirmed in a 2005 study that included 25 emergency medicine physicians, 21 of whom were ATLS-certified. 8 Twenty-two (88%) of the physicians named a correct location, but only 15 (60%) were able to identify it on a human volunteer. Radiologic Decompression As patients become larger and the standard catheter length remains unchanged, entering the pleural space becomes more difficult, which may lead to failed decompressions and worse outcomes. This issue was examined by a series of retrospective studies that utilized CT imaging to document chest wall thickness (CWT) and radiographic decompression based on catheter length. One study conducted in a U.S. region with a patient population known to have higher obesity rates compared CT radiographic needle compression success based on catheter length. Unsurpris- ingly, the longer the catheter length, the higher the predicted success rate. Results showed that the standard 4.6-cm catheter would reach the pleural space in 52.7% of the population, the 5.1-cm catheter would reach it in 64.8%, and the 6.4-cm catheter would reach it in 79%. 4 Similarly, a 2009 study looked at chest wall thickness at the 2ICS-MCL in trauma patients. Using CT scans of 110 patients, it noted that using a standard-size angio- catheter (4.4 cm), needle decompression would be unsuccess- AS PATIENTS BECOME LARGER, ENTERING THE PLEURAL SPACE BECOMES MORE DIFFICULT.