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Ultrasound Investigation of the Fifth Intercostal Space Landmark for Chest Tube Thoracostomy Site Selection in
Mason R Ruthford1, Aalap Shah2, Bethany J Wolf3
1From the Department of Emergency Medicine, University of South Dakota Sanford School of Medicine at Sanford Health, Sioux Falls, SD.
Insights
The traditional fifth intercostal space (ICS) for pediatric chest tube placement is often unsafe, with diaphragms frequently crossing into this area. Point-of-care ultrasound (POCUS) can identify these risks before procedures.
Area of Science:
- Pediatric Emergency Medicine
- Thoracic Surgery
- Diagnostic Imaging
Background:
- Chest tube thoracostomy is a common procedure for pediatric patients with pleural abnormalities.
- Traditionally, the fifth intercostal space (ICS) is used for chest tube placement based on anatomical landmarks.
- Previous studies in adults suggest the fifth ICS may be unsafe, but this has not been evaluated in children.
Purpose of the Study:
- To evaluate the safety of the fifth ICS for chest tube placement in pediatric patients.
- To identify patient factors associated with an unsafe fifth ICS for chest tube thoracostomy.
Main Methods:
- An observational study using point-of-care ultrasound (POCUS) in a pediatric emergency department.
- Safety was defined as the diaphragm not appearing within or above the fifth ICS during respiration.
- Univariate and multivariable analyses were performed to identify correlating patient factors.
Main Results:
- The diaphragm crossed into or above the fifth ICS in 10.3% of patients during tidal respiration and 27.2% during maximal respiration.
- Diaphragmatic crossing was more frequent on the right side, especially during maximal respiration (45.0%).
- Increased body mass index correlated with a higher likelihood of the diaphragm crossing the fifth ICS.
Conclusions:
- A significant proportion of pediatric patients have diaphragms that encroach upon the fifth ICS, posing a risk for chest tube placement.
- POCUS is a valuable tool for rapidly assessing the safety of the fifth ICS before pediatric chest tube thoracostomy.
- Routine POCUS pre-procedure is recommended to mitigate potential complications.
Objectives:
Chest tube thoracostomy site selection is typically chosen through landmark identification of the fifth intercostal space (ICS). Using point-of-care ultrasound (POCUS), studies have shown this site to be potentially unsafe in many adults; however, no study has evaluated this in children. The primary aim of this study was to evaluate the safety of the fifth ICS for pediatric chest tube placement, with the secondary aim to identify patient factors that correlate with an unsafe fifth ICS.
Methods:
This was an observational study using POCUS to evaluate the safety of the fifth ICS for chest tube thoracostomy placement using a convenience sample of pediatric emergency department patients. Safety was defined as the absence of the diaphragm appearing within or above the fifth ICS during either tidal or maximal respiration. Univariate and multivariable analyses were used to identify patient factors that correlated with an unsafe fifth ICS.
Results:
Among all patients, 10.3% (95% confidence interval [CI] 6.45-16.1) of diaphragm measurements crossed into or above the fifth ICS during tidal respiration and 27.2% (95% CI 19.0-37.3) during maximal respiration. The diaphragm crossed the fifth ICS more frequently on the right when compared with the left, with an overall rate of 45.0% (95% CI 36.1-54.3) of right diaphragms crossing during maximal respiration. In both univariate and multivariate analyses, a 1-kg/m 2 increase in body mass index was associated with an increase of 10% or more in the odds of crossing during both tidal and maximal respiration ( P = 0.003 or less).
Conclusions:
A significant number of pediatric patients have diaphragms that cross into or above the fifth ICS, suggesting that placement of a chest tube thoracostomy at this site would pose a significant complication risk. POCUS can quickly and accurately identify these unsafe sites, and we recommend it be used before pediatric chest tube thoracostomy.
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