Finding the fifth intercostal space for chest drain insertion

guidelines and ultrasound

J. S. Bowness, K. Nicholls, P. M. Kilgour (Lead / Corresponding author), J. Ferris, S. Whiten, I. Parkin, J. Mooney, P. Driscoll

    Research output: Contribution to journalArticle

    3 Citations (Scopus)

    Abstract

    OBJECTIVES: International guidelines exist for chest drain insertion and recommend identifying the fifth intercostal space or above, around the midaxillary line. In a recent study, applying these guidelines in cadavers risked insertion in the 6th intercostal space or below in 80% of cases. However, there are limitations of cadaveric studies and this investigation uses ultrasound to determine the intercostal space identified when applying these guidelines in healthy adult volunteers.

    METHODS: On each side of the chest wall in 31 volunteers, the position for drain insertion was identified using the European Trauma Course method, Advanced Trauma Life Support (ATLS) method, British Thoracic Society's 'safe triangle' and the 'traditional' method of palpation. Ultrasound imaging was used to determine the relationship of the skin marks with the underlying intercostal spaces.

    RESULTS: Five methods were assessed on 60 sides. In contrast to the cadaveric study, 94% of skin marks lay over a safe intercostal space. However, the range of intercostal spaces found spanned the second to the seventh space. In 44% of women, the inferior boundary of the 'safe triangle' and the ATLS guidelines located the sixth intercostal space or below.

    CONCLUSIONS: Current guidelines often identify a safe site for chest drain insertion, although the same site is not reproducibly found. In addition, women appear to be at risk of subdiaphragmatic drain insertion when the nipple is used to identify the fifth intercostal space. Real-time ultrasonography can be used to confirm the intercostal space during this procedure, although a safe guideline is still needed for circumstances in which ultrasound is not possible.

    Original languageEnglish
    Pages (from-to)951-954
    Number of pages5
    JournalEmergency Medicine Journal
    Volume32
    Issue number12
    Early online date5 Oct 2015
    DOIs
    Publication statusPublished - 2015

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    Thorax
    Guidelines
    Advanced Trauma Life Support Care
    Ultrasonography
    Skin
    Nipples
    Palpation
    Thoracic Wall
    Cadaver
    Volunteers
    Healthy Volunteers
    Wounds and Injuries

    Cite this

    Bowness, J. S., Nicholls, K., Kilgour, P. M., Ferris, J., Whiten, S., Parkin, I., ... Driscoll, P. (2015). Finding the fifth intercostal space for chest drain insertion: guidelines and ultrasound. Emergency Medicine Journal, 32(12), 951-954. https://doi.org/10.1136/emermed-2015-205222
    Bowness, J. S. ; Nicholls, K. ; Kilgour, P. M. ; Ferris, J. ; Whiten, S. ; Parkin, I. ; Mooney, J. ; Driscoll, P. / Finding the fifth intercostal space for chest drain insertion : guidelines and ultrasound. In: Emergency Medicine Journal. 2015 ; Vol. 32, No. 12. pp. 951-954.
    @article{9a9e0ce8d1fd4c599541e1bff274af7a,
    title = "Finding the fifth intercostal space for chest drain insertion: guidelines and ultrasound",
    abstract = "OBJECTIVES: International guidelines exist for chest drain insertion and recommend identifying the fifth intercostal space or above, around the midaxillary line. In a recent study, applying these guidelines in cadavers risked insertion in the 6th intercostal space or below in 80{\%} of cases. However, there are limitations of cadaveric studies and this investigation uses ultrasound to determine the intercostal space identified when applying these guidelines in healthy adult volunteers.METHODS: On each side of the chest wall in 31 volunteers, the position for drain insertion was identified using the European Trauma Course method, Advanced Trauma Life Support (ATLS) method, British Thoracic Society's 'safe triangle' and the 'traditional' method of palpation. Ultrasound imaging was used to determine the relationship of the skin marks with the underlying intercostal spaces.RESULTS: Five methods were assessed on 60 sides. In contrast to the cadaveric study, 94{\%} of skin marks lay over a safe intercostal space. However, the range of intercostal spaces found spanned the second to the seventh space. In 44{\%} of women, the inferior boundary of the 'safe triangle' and the ATLS guidelines located the sixth intercostal space or below.CONCLUSIONS: Current guidelines often identify a safe site for chest drain insertion, although the same site is not reproducibly found. In addition, women appear to be at risk of subdiaphragmatic drain insertion when the nipple is used to identify the fifth intercostal space. Real-time ultrasonography can be used to confirm the intercostal space during this procedure, although a safe guideline is still needed for circumstances in which ultrasound is not possible.",
    author = "Bowness, {J. S.} and K. Nicholls and Kilgour, {P. M.} and J. Ferris and S. Whiten and I. Parkin and J. Mooney and P. Driscoll",
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    Bowness, JS, Nicholls, K, Kilgour, PM, Ferris, J, Whiten, S, Parkin, I, Mooney, J & Driscoll, P 2015, 'Finding the fifth intercostal space for chest drain insertion: guidelines and ultrasound', Emergency Medicine Journal, vol. 32, no. 12, pp. 951-954. https://doi.org/10.1136/emermed-2015-205222

    Finding the fifth intercostal space for chest drain insertion : guidelines and ultrasound. / Bowness, J. S.; Nicholls, K.; Kilgour, P. M. (Lead / Corresponding author); Ferris, J.; Whiten, S.; Parkin, I.; Mooney, J.; Driscoll, P.

    In: Emergency Medicine Journal, Vol. 32, No. 12, 2015, p. 951-954.

    Research output: Contribution to journalArticle

    TY - JOUR

    T1 - Finding the fifth intercostal space for chest drain insertion

    T2 - guidelines and ultrasound

    AU - Bowness, J. S.

    AU - Nicholls, K.

    AU - Kilgour, P. M.

    AU - Ferris, J.

    AU - Whiten, S.

    AU - Parkin, I.

    AU - Mooney, J.

    AU - Driscoll, P.

    N1 - Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

    PY - 2015

    Y1 - 2015

    N2 - OBJECTIVES: International guidelines exist for chest drain insertion and recommend identifying the fifth intercostal space or above, around the midaxillary line. In a recent study, applying these guidelines in cadavers risked insertion in the 6th intercostal space or below in 80% of cases. However, there are limitations of cadaveric studies and this investigation uses ultrasound to determine the intercostal space identified when applying these guidelines in healthy adult volunteers.METHODS: On each side of the chest wall in 31 volunteers, the position for drain insertion was identified using the European Trauma Course method, Advanced Trauma Life Support (ATLS) method, British Thoracic Society's 'safe triangle' and the 'traditional' method of palpation. Ultrasound imaging was used to determine the relationship of the skin marks with the underlying intercostal spaces.RESULTS: Five methods were assessed on 60 sides. In contrast to the cadaveric study, 94% of skin marks lay over a safe intercostal space. However, the range of intercostal spaces found spanned the second to the seventh space. In 44% of women, the inferior boundary of the 'safe triangle' and the ATLS guidelines located the sixth intercostal space or below.CONCLUSIONS: Current guidelines often identify a safe site for chest drain insertion, although the same site is not reproducibly found. In addition, women appear to be at risk of subdiaphragmatic drain insertion when the nipple is used to identify the fifth intercostal space. Real-time ultrasonography can be used to confirm the intercostal space during this procedure, although a safe guideline is still needed for circumstances in which ultrasound is not possible.

    AB - OBJECTIVES: International guidelines exist for chest drain insertion and recommend identifying the fifth intercostal space or above, around the midaxillary line. In a recent study, applying these guidelines in cadavers risked insertion in the 6th intercostal space or below in 80% of cases. However, there are limitations of cadaveric studies and this investigation uses ultrasound to determine the intercostal space identified when applying these guidelines in healthy adult volunteers.METHODS: On each side of the chest wall in 31 volunteers, the position for drain insertion was identified using the European Trauma Course method, Advanced Trauma Life Support (ATLS) method, British Thoracic Society's 'safe triangle' and the 'traditional' method of palpation. Ultrasound imaging was used to determine the relationship of the skin marks with the underlying intercostal spaces.RESULTS: Five methods were assessed on 60 sides. In contrast to the cadaveric study, 94% of skin marks lay over a safe intercostal space. However, the range of intercostal spaces found spanned the second to the seventh space. In 44% of women, the inferior boundary of the 'safe triangle' and the ATLS guidelines located the sixth intercostal space or below.CONCLUSIONS: Current guidelines often identify a safe site for chest drain insertion, although the same site is not reproducibly found. In addition, women appear to be at risk of subdiaphragmatic drain insertion when the nipple is used to identify the fifth intercostal space. Real-time ultrasonography can be used to confirm the intercostal space during this procedure, although a safe guideline is still needed for circumstances in which ultrasound is not possible.

    U2 - 10.1136/emermed-2015-205222

    DO - 10.1136/emermed-2015-205222

    M3 - Article

    VL - 32

    SP - 951

    EP - 954

    JO - Emergency Medicine Journal

    JF - Emergency Medicine Journal

    SN - 1472-0205

    IS - 12

    ER -