Finding the fifth intercostal space for chest drain insertion: guidelines and ultrasound

Point-of-care ultrasound thoracic “Quick Look” identifies potentially dangerous chest tube insertion sites

PURPOSE

Emergency and trauma physicians typically rely on anatomic landmarks to determine the proper intercostal space for emergent tube thoracostomy. However, physicians using this technique select a potentially dangerous insertion site too inferior in nearly one-third of cases, which have the potential to result in subdiaphragmatic puncture. We investigated a point-of-care ultrasound (POCUS) thoracic "Quick Look" procedure as a technique to allow visualization of underlying structures to avoid tube misplacement.

METHODS

We performed an observational study of adult emergency department patients and their treating physicians. The patient's emergency physician was asked to rapidly identify and mark a hypothetical tube thoracostomy insertion site on the patient's chest wall. An ultrasound fellow then performed a POCUS thoracic "Quick Look" exam with a phased-array probe placed directly over the marked site. Over one regular respiratory cycle, the identification of standard lung pattern was considered a negative scan whereas visualization of the diaphragm with underlying liver or spleen was considered a positive scan. Time for completion of the "Quick Look" scan was measured and inter-rater reliability was determined through image review by a single, blinded ultrasound director.

RESULTS

Seventy-six thoracic "Quick Look" scans were performed on patient subjects, of which 17% (13/76, 95%CI 8-26%) were positive. The average time for performing the "Quick Look" exam was 43 s (95%CI 30-57). Inter-rater reliability of the thoracic "Quick Look" was excellent (κ = 0.95).

CONCLUSION

Thoracic "Quick Look" exams performed at mock chest tube insertion sites demonstrated potentially dangerous insertions in 17% of the cases. POCUS thoracic "Quick Look" may be a rapid and reliable technique that improves safety when placing an emergent chest tube.

Adverse events related to thoracentesis and chest tube insertion: evaluation of the national collection of subject safety incidents in Japan

PURPOSE

Thoracentesis and chest tube insertion are procedures commonly performed in routine clinical practice and are considered mandatory skills for all physicians. Adverse events secondary to these procedures have been widely reported; however, epidemiology data concerning life-threatening events associated with these procedures are lacking.

METHODS

We retrospectively analyzed data from the Japan Council for Quality Health Care open database regarding subject safety incidents involving thoracentesis and chest tube insertion. The adverse events extracted from the database included only events associated with thoracentesis and chest tube insertion reported between January 2010 and April 2020.

RESULTS

We identified 137 adverse events due to thoracentesis or chest tube insertion. Our analysis also revealed at least 15 fatal adverse events and 17 cases of left/right misalignment. Not only resident doctors but also physicians with 10 years or more of clinical experience had been mentioned in these reports. The most common complications due to adverse events were lung injury (55%), thoracic vascular injury (21%), and liver injury (10%). Surgical treatment was required for 43 (31%) of the 137 cases, and the mortality risk was significantly higher for thoracic vascular injury than for other complications (p = 0.02).

CONCLUSION

We identified at least 15 fatal adverse events and 17 cases of left/right misalignment over a 10-year period in the Japan Council for Quality Health Care open database. Our findings also suggest that care should be taken to avoid thoracic vascular injury during chest tube insertion and that immediate intervention is required should such an injury occur.

The Nipple as a Landmark for Needle Decompression of Tension Pneumothorax in Children - A CT-Based Evaluation and Proposal of an Alternative Insertion Site

OBJECTIVE

Needle decompression of tension pneumothorax in children is a rarely encountered but potentially life-saving procedure, that is accompanied by a certain risk of injury. We evaluated the nipple as a landmark for an alternative anterior insertion site and as an aid in localizing lateral insertion sites, as well as its influence on the safety profile of the procedure.

METHODS

In thoracic computer tomography scans of children aged 0-10 years, the distance to the closest vital structure was compared between the traditional anterior insertion site (2nd intercostal space midclavicular line) and an alternative anterior insertion site (2nd intercostal space at the nipple line). Furthermore, the level of the nipple at the midaxillary line was investigated as guidance in quickly localizing the lateral insertion site and ensuring an insertion site high enough to avoid intraabdominal injury by the decompression needle. Additionally, correlation of these measures with age was investigated.

RESULTS

The distance to the closest vital structure at the 2nd intercostal space was significantly bigger at the nipple line compared to the midclavicular line (right: 2.23 ± 1.13 cm vs. 0.99 ± 0.80 cm, p < 0.0001; left: 1.92 ± 1.19 cm vs. 0.81 ± 0.70 cm, p < 0.0001). At the midaxillary line, the level of the nipple was at the 4th or 5th intercostal space in the majority of children (right: 83.8%; left: 88.1%). The mean distance from the nipple to the diaphragmatic cupola was 2.63 ± 1.85 cm on the right and 3.40 ± 1.86 cm on the left hemithorax.

CONCLUSION

When performing anterior needle decompression in children, we recommend inserting the needle at the more lateral insertion site at the 2nd intercostal space at the nipple line. At the lateral decompression sites, the nipple can be used as a marker for localizing the correct intercostal space for insertion and thereby ensuring enough caudad distance to the diaphragm to avoid abdominal injury.

Sonogram of safety: Ultrasound outperforms the fifth intercostal space landmark for tube thoracostomy site selection

PURPOSE

Identification of tube thoracostomy insertion location is currently performed using a blind, landmark based approach at either the fifth intercostal space (ICS) or inframammary crease in the midaxillary line. A significant percentage of thoracostomies at this site result in complications. This pilot study aimed to assess whether bedside ultrasound could aid in identifying safer tube thoracostomy insertion sites in emergency department patients.

METHODS

Fifty emergency department patients were enrolled in this study. Right and left hemidiaphragms were evaluated with ultrasound at the fifth ICS. Observations were made on if the diaphragm was below, above, or crossed the fifth ICS during an entire respiratory cycle.

RESULTS

Eighty-one (95% confidence interval 72-82) of the diaphragms were below, 13 (95% confidence interval 8-21) of the diaphragms were at, and 6 (95% confidence interval 3-12) of the diaphragms were above the location marked using traditional landmark techniques. On the right and left hemidiaphragms, 20% (95% confidence interval 19.9%-20.1%) and 18% (95% confidence interval 17.9%-18.1%) of diaphragms were above or crossing the fifth ICS, respectively CONCLUSIONS: Ultrasound identified a significant number of potential chest tube insertion sites at the fifth ICS that would result in subdiaphragmatic insertion or diaphragmatic injury. Based on this data ultrasound can be used to identify safer insertion sites and reduce thoracostomy complications.

Ultrasound versus manipulation to determine an intercostal space for single-port thoracoscopy surgery: a diagnostic accuracy study

Background

Malposition of the intercostal space used for single-port thoracoscopy surgery can lead to problems. This study was to assess the accuracy of point-of-care ultrasound in verifying the position of intercostal space.

Methods

A total of 200 patients, ASA (American Society of Anesthesiologists) physical status I or II, who underwent single-port thoracoscopic lobectomy, were enrolled. After the induction of anesthesia, a thoracic team confirmed the incision position. Firstly, the intercostal space was located by a young resident thoracic surgeon by ultrasound. Secondly, the intercostal space was located by an experienced thoracic surgeon by manipulation. Finally, the investigator verified the location of the intercostal space under direct vision through thoracoscopy, which was recognized as standard method. The time required by ultrasound and manipulation were recorded.

Results

The inter-relationships between ultrasound and the standard method and between manipulation and the standard method were consistent. Manipulation positioning showed a sensitivity of 90.6% and specificity of 30% while ultrasound positioning showed a sensitivity of 87.1% and specificity of 60%. The specificity of ultrasound positioning was higher than that of manipulation position. The time required by ultrasound was shorter than that required by manipulation.

Conclusions

Compared with the manipulation method, the ultrasound-guided method could accurately locate the intercostal space. Ultrasound requires less time than manipulation.

Trial registration

ISRCTN10722758. Registered 04 June 2019

Thoracostomy in children with severe trauma: An overview of the paediatric experience in Victoria, Australia

OBJECTIVE

Thoracic trauma is a leading cause of paediatric trauma deaths. Traumatic cardiac arrest, tension pneumothorax and massive haemothorax are life-threatening conditions requiring emergency and definitive pleural decompression. In adults, thoracostomy is increasingly preferred over needle thoracocentesis for emergency pleural decompression. The present study reports on the early experience of thoracostomy in children, to inform debate regarding the best approach for emergency pleural compression in paediatric trauma.

METHODS

Retrospective review of Ambulance Victoria and The Royal Children's Hospital Melbourne, Trauma Registry between August 2016 and February 2019 to identify children undergoing thoracostomy for trauma, either pre-hospital or in the ED.

RESULTS

Fourteen children aged 1.2-15 years underwent 23 thoracostomy procedures over the 31 month period. The majority of patients sustained transport-related injuries, and underwent thoracostomies for the primary indications of hypoxia and hypotension. Two children were in traumatic cardiac arrest. Ten children underwent needle thoracocentesis prior to thoracostomy, but all required thoracostomy to achieve the necessary definitive decompression. All patients were severely injured with multiple-associated serious injuries and median Injury Severity Score 35.5 (17-75), three of whom died from their injuries. Thoracostomy in our cohort had a low complication rate.

CONCLUSION

In severely injured children, thoracostomy is an effective and reliable method to achieve emergency pleural decompression, including in the young child. The technical challenges presented by children are real, but can be addressed by training to support a low complication rate. We recommend thoracostomy over needle thoracocentesis as the first-line intervention in children with traumatic cardiac arrest, tension pneumothorax and massive haemothorax. [Correction added on 23 September 2019 after first online publication: in the second sentence of the conclusion, the words "under review process" were mistakenly added and have been removed.].