Intercostal Chest drain insertion

Last Updated on by frcemuser


  • Primary pneumothorax following unsuccessful aspiration.
  • Secondary pneumothorax.
  • Tension pneumothorax following needle decompression
  • Haemothorax.
  • Pneumothorax in a ventilated patient.
  • Empyema and complicated parapneumonic effusions (pleural fluid pH<7.2).
  • Malignant pleural effusion for symptomatic relief
  • Large pleural effusions of other etiology.


  • Inexperience with technique.
  • Refusal by a competent patient.
  • Deranged INR/platelets (stop warfarin and correct any coagulopathy).
  • Local Infection
  • Lung adherent to the chest wall.

Types of chest drain

  • Seldinger chest drains are usually smaller drains which are inserted by advancing the drain over a guidewire.
  • Large-bore drains are recommended for acute haemothorax to monitor blood loss and may also be necessary if a pneumothorax has failed to resolve despite a smaller drain.


  • The 5th intercostal space anterior to the mid-axillary line for most situations.
  • Chest drains should be inserted within the ‘triangle of safety’.With the arm abducted, the apex is the axilla, and the the triangle is formed by the:
    • Lateral border of the pectoralis major anteriorly
    • Anterior border of the latissimus dorsi posteriorly
    • Inferiorly, by a line superior to the horizontal level of the nipple and an apex below the axilla


Ultrasound guidance: Recent research regarding the morbidity and mortality of chest drain insertion strongly recommends insertion of chest drains under ultrasound guidance.

Drain Insertion: The needle should be inserted just above the upper border of the rib to avoid the intercostal neurovascular bundle.

Confirmation: if the drain is correctly positioned it should swing with respiration and drain fluid or air.


  • Pain (prescribe simple and/or opioid analgesia).
  • Infection.
  • Bleeding from intercostal vessels.
  • Damage to intercostal nerves.
  • Poor position of drain: may need withdrawing slightly.
  • Blockage of drain: may require flush with 10 mL sterile saline.
  • Organ damage: do not insert the sharp trocar into the pleural cavity.
  • Bleeding: stop warfarin before insertion and correct any coagulopathy.
  • Surgical emphysema may occur with pneumothorax.
  • Re-expansion pulmonary oedema(rapid re-expansion of the lung may cause non-cardiogenic pulmonary oedema)

Needle thoracocentesis


  • Second intercostal space (identified by tracing along from the angle of Louis on the sternum)
  • Mid-clavicular line
  • On the side of the pneumothorax

Post procedures

  • Insert a definitive chest drain.
  • Perform a CXR


  • Bleeding or local haematoma
  • Damage to the neurovascular bundle (runs below each rib)
  • Re-tension due to tube kinking, dislodging, or failure to progress to a definitive chest drain
  • Creation of a pneumothorax
  • Lung laceration

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