Can a chest drain be inserted in the anterior axillary line?

Chest Drain Insertion in the Anterior Axillary Line

Yes, a chest drain can be safely inserted in the anterior axillary line, but the mid-axillary line within the 'safe triangle' is the optimal and preferred location for chest drain insertion. 1

Optimal Chest Drain Insertion Location

The British Thoracic Society recommends the following for chest drain placement:

• The 'safe triangle' in the mid-axillary line is the preferred location, specifically between the 4th and 5th intercostal space 1
• This 'safe triangle' is anatomically defined as:
  • Bordered by the anterior border of latissimus dorsi
  • Bordered by the lateral border of pectoralis major muscle
  • A line superior to the horizontal level of the nipple
  • An apex below the axilla 1

Anatomical Considerations

When considering anterior axillary line placement, be aware of these important anatomical factors:

• Intercostal arteries run in the middle of intercostal spaces posteriorly, but laterally they run under the ribs 1
• This creates a higher risk of traumatic insertion if drains are placed posteriorly 2
• The neurovascular bundle is not always safely protected in the subcostal groove as traditionally taught 3
• A 2015 cadaveric study found that chest drain insertion guidelines may result in placement below the fifth intercostal space in 83% of cases, potentially risking injury to subdiaphragmatic structures 4

Patient Positioning for Drain Insertion

For optimal access to the anterior or mid-axillary line:

• For cooperative patients under local anesthesia: Position slightly rotated with the arm on the affected side behind the patient's head to expose the axillary area 2, 1
• Alternative positions include:
  • Upright leaning over a table with a pillow
  • Lateral decubitus position 2, 1
• For patients under general anesthesia: Position flat on their back, with adjustment if the marked site is posterior 2, 1

Technical Considerations

To minimize complications when inserting a chest drain in the anterior axillary line:

• Use ultrasound guidance to identify the exact location for insertion 1
• Use small drains (8-12 FG) as they are as effective as larger tubes while causing less discomfort 2, 1
• Never use substantial force or trocars during insertion to avoid traumatic complications 2
• The "Safe Zone" for drain insertion is narrower than traditionally taught and should be between 50-70% of the way down an interspace to avoid the variably positioned superior intercostal neurovascular bundle 3
• Always perform a chest radiograph after insertion to check drain position and ensure a pneumothorax has not developed 2, 1

Safety of Anterior vs. Mid-Axillary Approach

While the anterior axillary line can be used, research supports the mid-axillary approach:

• A 2015 study identified the 4th or 5th intercostal space in the mid- or anterior-axillary line as appropriate sites for chest tube placement 5
• A 2009 study specifically examining neonates found that "the anterior to midaxillary line between the 4th or 5th intercostal space (Buelau position) is safe for the use of thoracostomy tubes in preterm and term infants" 6

Potential Complications to Avoid

Be vigilant about these potential complications:

• Hemothorax, lung lacerations, and injury to thoracic or abdominal organs 5
• Subdiaphragmatic insertion risking injury to abdominal structures 4
• Damage to peripheral nerves of the lateral thoracic wall 4
• In rare cases, cardiac perforation has been reported with improper placement 7