Landmark for Pleural Taping (Thoracentesis/Drainage)
The standard landmark for pleural drainage is the fifth or sixth intercostal space in the anterior axillary line 1.
Anatomical Positioning
The fifth intercostal space at the midaxillary line is the optimal site for pleural procedures, providing superior success rates and safety compared to other locations 1, 2.
The anterior axillary line (between the anterior and mid-axillary lines) at the 5th-6th intercostal space represents the safest approach, balancing accessibility with minimal risk of injury 1.
This location avoids the costophrenic angle and apical regions where pleural plaques and anatomical variations are more common 3.
Critical Safety Considerations
Ultrasound guidance should be used to identify the pleural effusion and guide needle placement, as this significantly improves safety and success rates compared to landmark-based techniques alone 3.
The chest wall thickness at the fifth intercostal space averages 3.5 cm (±0.9 cm), which is approximately 1 cm thinner than the second intercostal space, making successful pleural access more reliable 2.
Avoid trocar insertion due to significantly increased risk of injury—use a controlled, non-forceful technique with direct visualization or ultrasound guidance 1.
Common Pitfalls to Avoid
Do not use the second intercostal space, midclavicular line for pleural drainage, as this location has only a 57.5% success rate for pleural cavity access and carries higher pneumothorax risk 2.
The pleural reflection reaches the level of the 10th rib in the midaxillary line, so procedures below this level risk traversing pleura, diaphragm, and peritoneum 4.
Avoid the intercostal approach in patients with emphysema, anxiety, or significant pleural thickening when possible, as these conditions increase complication risk 4.
Ultrasound Integration
Ultrasound allows visualization of the anechoic space between the pleurae and enables real-time guidance for needle placement, which is considered a basic skill for intensivists 3.
The diaphragm should be identified as a key landmark to correctly distinguish intrathoracic from intra-abdominal structures 3.
A structured six-area per hemithorax approach (anterior, lateral, and posterior fields divided by sternum, anterior and posterior axillary lines) ensures complete thoracic assessment 3.
Procedure Technique
Position the patient upright or semi-recumbent with the arm abducted to expose the lateral chest wall 1.
Use sterile technique throughout, including sterile gloves, gown, equipment, and skin preparation 5.
The complication rate for correctly placed pleural drainage does not exceed 3%, with typical complications including malposition, hemorrhage, or infection 1.