Chest Tube Placement: Is the Nipple a Reliable Landmark?
Can you use nipple location as a physical landmark for chest tube placement?
Is it the same for men and women?
BLUF: No.
🕖 Reading Time, 4 minutes
Using the nipple as a marker for the 5th ICS as recommended by ATLS and the British Thoracic Society safe triangle guidelines to identify the correct location for chest tube insertion actually correlated with the 6th ICS or below in 14 of 32 supine females. Whereas in supine males it identified it correctly in 27 of 28 volunteers. Actual location was confirmed with ultrasound. Study participants had a mean age of 19.5 years old. There was no comment on BMI. Even in young supine females, using the nipple to try and identify the 5th intercostal space is inaccurate.1
The 10th Ed of the Advanced Trauma Life Support course also states you can use the inframammary fold as a reference to diaphragm location. I cannot find any peer reviewed literature evaluating the accuracy of that technique.
Using the nipple location to insert chest tubes is inaccurate for 50% of the population who are women and the inframammary fold seems unstudied.
That’s bad.
How about just counting down to find the right spot?
BLUF: Better, but still misidentifies the correct location in 26% of females.
In a study of 50 volunteers (19 females and 31 males) aged 23 to 87 years old, direct palpation of their chest wall to identify the 5th intercostal space for chest tube insertion was accurate in only 74% of females and 85% of males (compared to ultrasound). If the 5th intercostal space was misidentified, it meant placement was actually at or below the diaphragm, which would result in chest tube placement intra-abdominally.2
We need to consider the importance of being able to treat all of our casualties, not just 50% of the population.
References:
1Finding the fifth intercostal space for chest drain insertion: guidelines and ultrasound. Bowness JS, Nicholls K. Emerg Med J. 2015 Dec;32(12):951-4.
2Sonogram of safety: Ultrasound outperforms the fifth intercostal space landmark for tube thoracostomy site selection. Gray EJ, Cranford JA, Betcher JA. J Clin Ultrasound. 2020 Jul;48(6):303-306.
For an interesting read on the artist Suzanne Valadon, check out this article on CNN Style (the first time a Style article has been cited by Crisis Medicine…)
