What is the recommended location and size for chest tube placement in adults?

Recommended Location and Size for Chest Tube Placement in Adults

For adult chest tube placement, the recommended location is the 4th or 5th intercostal space in the mid-axillary line using a small-bore tube (14F or smaller) for most indications. 1

Optimal Location for Chest Tube Insertion

• The most appropriate site for chest tube placement is the 4th or 5th intercostal space in the mid-axillary or anterior-axillary line 1, 2
• For needle decompression in tension pneumothorax, the 5th intercostal space along the mid-axillary line has shown 100% success rate compared to only 57.5% success at the traditional 2nd intercostal space mid-clavicular line position 3
• The chest wall is approximately 1 cm thinner at the 5th intercostal space (3.5 cm ± 0.9 cm) compared to the 2nd intercostal space (4.5 cm ± 1.1 cm), which may improve successful needle placement 3
• For left-sided tension pneumothorax, the 2nd intercostal space along the midclavicular line may be safer due to potential risk of cardiac injury at the 5th intercostal space 4

Recommended Chest Tube Size

• Small-bore chest tubes (14F or smaller) should be used initially for most indications 4
• The British Thoracic Society (BTS) guidelines recommend initial drainage of pleural infection using a small-bore chest tube (14F or smaller) 4
• There is no evidence that large tubes (20-24F) are better than small tubes (10-14F) in the management of pneumothoraces 4
• Small-bore tubes (10-14F) have shown primary success rates of 84-97% in treating pneumothoraces 4
• Factors that might necessitate larger tubes include:
  • Presence of pleural fluid 4
  • Large air leak that exceeds the capacity of smaller tubes 4
  • Persistent air leak requiring replacement of a small tube with a larger one 4

Insertion Technique Considerations

• The trocar technique should be avoided due to significantly increased risk of injury 2
• Blunt dissection (for tubes >24F) or the Seldinger technique should be used instead 5
• Chest tube insertion should be guided by imaging when possible, either bedside ultrasonography or computed tomography 5
• For central venous catheters (which follow similar principles), the tip should lie outside the pericardial sac to avoid the risk of pericardial effusion/tamponade 4

Common Complications and How to Avoid Them

• Complications occur in approximately 3% of properly placed chest tubes 2
• Common complications of small-bore drains include pain, drain blockage, and accidental dislodgment 5
• More serious complications include:
  • Hemothorax from intercostal vessel injury 1
  • Lung laceration 1
  • Injury to thoracic or abdominal organs 1
  • Infection including empyema (estimated at 1% after chest tube insertion) 4
  • Re-expansion pulmonary edema 5
• To minimize complications:
  • Use proper aseptic technique during insertion or manipulation of chest drainage systems 4
  • Avoid clamping a chest tube that is still bubbling, as this may convert a simple pneumothorax into a tension pneumothorax 4
  • Ensure proper positioning and fixation to prevent dislodgment 1

Special Considerations

• For tension pneumothorax, a 7 cm needle may be appropriate for decompression at either the 5th intercostal space along the midaxillary line or the 2nd intercostal space along the midclavicular line 4
• For electrical impedance tomography monitoring, belt positioning is typically between the 4th and 5th intercostal space in a transverse plane 4
• Indwelling pleural catheters represent a first-line palliative therapy for malignant pleural effusions in many centers 5

By following these evidence-based recommendations for chest tube placement location and size selection, clinicians can optimize patient outcomes while minimizing potential complications.