Where should I insert an intercostal chest tube?

Intercostal Chest Tube Placement Location

Insert the intercostal chest tube in the 4th or 5th intercostal space within the "safety triangle" bounded by the lateral edge of pectoralis major anteriorly, the anterior edge of latissimus dorsi posteriorly, and a horizontal line at the nipple level (5th intercostal space) superiorly. 1

Anatomical Landmarks: The Safety Triangle

The safety triangle provides the safest anatomical corridor for chest tube insertion:

• Anterior boundary: Lateral edge of the pectoralis major muscle 1
• Posterior boundary: Anterior edge of the latissimus dorsi muscle 1
• Superior boundary: Horizontal line at nipple level, corresponding to the 5th intercostal space 1
• Apex: Located at the axillary apex 1

This corresponds to the anterior to mid-axillary line at the 4th or 5th intercostal space (Bülau position), which is the standard recommended site. 2, 3, 4, 5

Critical Safety Considerations

Never insert posterior to the safety triangle - this places intercostal vessels in a more exposed position and markedly increases the risk of traumatic vascular injury. 1

Avoid insertion below the 5th intercostal space - inserting too inferiorly risks penetrating the diaphragm and injuring intra-abdominal organs (liver, spleen, stomach). 5

Patient Positioning

For optimal exposure of the insertion site:

• Cooperative patient: Position slightly rotated with the arm on the affected side behind the head to expose the axillary area 1
• Alternative positions: Upright, slightly forward-leaning on an adjacent table with pillow support, or lateral decubitus 1
• Under general anesthesia: Position supine and rotate the torso if the insertion site is markedly posterior 1

Insertion Technique Requirements

Use blunt dissection without substantial force and never use a trocar. 1, 2, 3, 5 Trocar use is associated with serious complications including:

• Hemothorax 1, 2
• Pulmonary lacerations 1, 2
• Injury to intrathoracic or abdominal organs 1, 2

For percutaneous insertion with dilators, sharp dissection of tissue is unnecessary. 1

Sterile Technique

Strict sterile technique is mandatory to prevent wound infection or secondary empyema:

• Thorough skin antisepsis with povidone-iodine or chlorhexidine over a wide area 1
• Sterile gloves, gown, instruments, and drapes 1

Post-Procedure Verification

A chest radiograph must be obtained after insertion to confirm correct tube placement and exclude pneumothorax. 1

Common Pitfalls

Malposition occurs in approximately 20-25% of cases with lateral approaches, most commonly interlobar placement. 6 However, clinically relevant malfunction requiring repositioning occurs in only about 6% of cases. 6 The complication rate for correctly placed tubes does not exceed 3%. 3

The ventral approach (2nd-3rd intercostal space in the midclavicular line/Monaldi position) is an alternative for emergency decompression but has a significantly higher risk of interlobar malposition when used laterally. 6, 5