What is the correct placement of an intercostal (between the ribs) drain?

Correct Placement of an Intercostal Drain

The most appropriate site for intercostal drain placement is the 4th or 5th intercostal space in the mid- or anterior-axillary line, within the "safe triangle" bordered by the lateral edge of pectoralis major muscle, anterior border of latissimus dorsi, and a line superior to the horizontal level of the nipple. 1

Anatomical Considerations

• Safe Triangle: The optimal placement area is within the "safe triangle" which includes:

  • Lateral border of pectoralis major muscle (anteriorly)
  • Anterior border of latissimus dorsi muscle (posteriorly)
  • Line superior to the horizontal level of the nipple (inferiorly)
  • This area minimizes risk of injury to vital structures 1

• Intercostal Space: 4th or 5th intercostal space is recommended 2, 3

  • Avoid the 2nd or 3rd intercostal space in the medioclavicular line as this is inappropriate for various reasons 4

Insertion Technique

Preferred Method

• Blunt Dissection Technique is strongly recommended over trocar insertion 1, 5
  • Trocar insertion significantly increases risk of organ injury and complications 5
  • Complication rates are higher when using sharp trocars 2

Step-by-Step Procedure

1. Position patient appropriately (usually supine or semi-recumbent)
2. Identify and mark the insertion site (4th/5th intercostal space, mid/anterior axillary line)
3. Administer adequate local anesthesia (infiltrate down to the pleura)
4. Make an incision parallel to the rib (to avoid neurovascular bundle)
5. Perform blunt dissection through chest wall
6. Enter pleural space just above the rib (to avoid the neurovascular bundle)
7. Insert finger to confirm entry into pleural space and ensure no adhesions
8. Guide the tube into position without using force
9. Secure the tube and connect to drainage system

Special Considerations

Drain Direction

• For pneumothorax: Direct the tube apically (toward the dome of the pleura) 4
• For fluid collections: Direct the tube posteriorly and inferiorly

Drain Size

• Small-bore tubes (10-14F): Suitable for most pleural effusions using Seldinger technique 1
• Larger tubes: May be needed for hemothorax or thick empyema

Imaging Guidance

• Ultrasound guidance is strongly recommended for marking the optimal insertion site, especially for pleural effusions 1
• This reduces risk of complications and improves placement accuracy

Avoiding Complications

Common complications include:

• Organ injury (lung, heart, liver, spleen)
• Intercostal vessel injury causing hemothorax
• Tube malposition
• Infection

To minimize these risks:

• Always use blunt dissection rather than trocar insertion 1, 5
• Never use substantial force during insertion 1
• Maintain strict aseptic technique
• Ensure proper anatomical positioning within the safe triangle
• Use ultrasound guidance when available
• Never clamp a bubbling chest tube 6, 1

Post-Procedure Management

• Connect to underwater seal drainage system
• Keep drainage system below chest level
• Monitor for air leaks and drainage
• Obtain post-procedure chest radiograph to confirm position

The complication rate for properly placed chest tubes should not exceed 3% 5, highlighting the importance of proper technique and anatomical placement within the recommended safe triangle.