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Emergency Medicine Australasia (2015) 27, 66–68
CLINICAL PROCEDURES
Intercostal catheter insertion
Ben BUTSON and Paul KWA
Emergency Department, Townsville Hospital, Townsville, Queensland, Australia
Evidence-based medicine continues to
whittle away at the list of ‘absolute in-
dications’ for intercostal catheter (ICC)
insertion. The inevitable consequence
is that fewer opportunities are pre-
sented to emergency physicians and
trainees to perform this important pro-
cedure. But it remains one of the key
surgical skills for our discipline. Like
all articles in this editorial segment, it
is not our intention to teach the basics
of the procedure. Rather, this article
discusses some of the relevant ques-
tions and controversies.
What is the optimal patient
position and insertion site
for an ICC?
• If possible, the patient should be semi-
erect with the head of bed at 45%
degrees. This helps lower the dia-
phragm and decrease risk of injury
to abdominal organs.1 The ipsilat-
eral arm is abducted and externally
rotated as much as possible, with the
patient’s hand placed behind their
head and restrained there.
• Textbooks and conventional teach-
ing often refer to the Triangle of
Safety2 for placement. Unfortunate-
ly, it is alarmingly common for the
ICC to be placed too low in the chest.3
A thoracostomy incision should be
at a level superior to the nipple line,
in the axilla. A good guide is the in-
ferior margin of the axillary hair-
line – in most patients the correct
placement will be one finger breadth
below this.
Correspondence: Dr Ben Butson, Emergency Department, Townsville Hospital, Towns-
ville, QLD 4814, Australia. Email: ben.butson@health.qld.gov.au
Ben Butson, BSc (Hons), BMBS (Hons), FACEM, FACRRM, FRACGP, Grad Dip Rural
GP, GCertSportsMed, CCPU, Emergency and Retrieval Physician; Paul Kwa, MBBS
(Hons), MPH&TM, GCertAeroMedRet, FACEM, Emergency Physician.
Accepted 24 November 2014
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
• Adoption of the term ‘Lower Axil-
lary ICC’ might help to emphasise
the correct location.
What analgesia and/or
sedation should I give
my patient?
• Fifty per cent of patients experi-
enced pain levels of ≥9/10 during
chest drain insertion.4 The authors
often utilise procedural sedation
during ICC insertion, most com-
monly a combination of fentanyl
and ketamine.
• Administer generous local anaes-
thesia (10 mL of 1% lignocaine with
adrenaline) along the entire antici-
pated track of the ICC, especially to
the pain-sensitive parietal pleura. As-
piration of the expected pleural con-
tents during administration of local
anaesthesia also helps confirm ac-
curate site selection.
• Intra-pleural injection of 10–20 mL
of 0.25% bupivacaine after inser-
tion of the drain improves patient
tolerance.5,6
What instruments work best
for blunt dissection?
• The aim of blunt dissection is to
avoid damage to the intercostal
neurovascular bundle, and the
underlying lungs or heart.
• Excessive effort during blunt dis-
section can cause forceful entry into
the pleural cavity. Instruments that
are too blunt, such as large Spencer
doi: 10.1111/1742-6723.12347
Wells forceps, might encourage this.
The authors suggest forceps with a
finer point for blunt dissection, such
as 16–18 cm Kelly or Robert’s
forceps. It does not matter whether
the forceps are straight or curved –
there are pros and cons for each.
Any tips for not losing my
tract into the pleural space?
• Following blunt dissection and pen-
etration through the pleura, always
leave a finger or instrument in the
pleural space until the ICC is in-
serted. This can be difficult in mor-
bidly obese patients – the very group
where the tract can be easily lost. A
bougie might be useful for guiding
an ICC into the chest for obese pa-
tients, so long as there is enough
length outside the chest to facili-
tate safe Seldinger technique.
• A balance exists between making a
wide enough pleural opening to
comfortably fit a finger and ICC,
with making too wide an opening,
which then predisposes to an air leak
and subcutaneous emphysema.
• Grasping the ICC with a clamp at-
tached to a distal drainage hole helps
facilitate insertion. A trocar should
not be used.
What size of ICC should
I use?
• Small bore ICCs should be
considered first line for drain-
age of pneumothoraces (8–14F)
and pleural effusions/empyemas
(20F).7–10
• Haemothoraces should be drained
with large bore ICCs (≥24F),
due to increased flow rates and
lower likelihood of blockage.9,10 Al-
though laboratory studies ques-
tion whether this is true once the
INTERCOSTAL CATHETER INSERTION
ICC size exceeds 8F,11 current evi-
dence is inadequate to change this
recommendation.
Where should I aim the
ICC towards?
• Evidence for best practice is lacking
and recommendations vary.1,2,12
• The authors aim all ICCs posteri-
orly and superiorly for two reasons:
• As the lung expands and the
pleural space reduces, air and fluid
will follow the path of least re-
sistance and enter a functioning
drainage tube, regardless of its
position.1
• Aiming superiorly, rather than in-
feriorly, reduces the likelihood of
intra-fissural placement.12
• Loculated collections are best
drained under radiological guidance.
How far should I insert
the ICC?
• Far enough to ensure that the most
proximal drainage hole is within the
pleural space.1 This is especially im-
portant in the obese.
• Once inserted rotate the ICC 360°
to reduce the likelihood of kinking.
Should I administer
prophylactic antibiotics
during ICC insertion?
• Not routinely. Antibiotics may be
considered in trauma patients, es-
pecially with penetrating trauma.1,2
Is a pre-hospital ICC more
likely to become infected?
• No. Empyema might complicate
2–12% of ICCs placed in hospital.
The rates are not higher for those
placed by experienced pre-hospital
physicians.13
When should I connect an
ICC to suction and
how much?
• Suction may be applied for a per-
sistent air leak or non-resolving
pneumothorax, although evidence
for or against its use is lacking.2,7
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
• Suction is usually limited to −10 to
−20 cm H 2 O. Depending on the
specific set-up this will be con-
trolled by either the volume of
water in the underwater seal drain-
age system, or a low pressure
adaptor connected directly to wall
suction.2
When should an ICC
be clamped?
• Clamping an ICC in the presence of
a continuing air leak might poten-
tially result in a tension pneumo-
thorax. Therefore a bubbling ICC
should never be clamped.
• The ICC should be clamped im-
mediately prior to disconnection
from the drainage system or
removal. Prolonged clamping of the
ICC as a trial prior to removal is not
recommended.2
• Do not clamp an ICC if draining a
massive haemothorax. It is better to
know how much blood has been
lost, and the rate of ongoing bleed-
ing. It is not possible to tamponade
bleeding by clamping the drain. A
functioning ICC will at least allow
the lung to reinflate and improve
ventilation.
• Re-expansion pulmonary oedema is
rare, but is more likely to occur after
rapid drainage of large, long-
standing collections. If more than
1000 mL of air or fluid is to be
drained, it is safest to clamp the
drain after the initial 1000 mL has
been drained and observe for
30 min, prior to draining the re-
mainder. This is only relevant
for chronic pneumothorax or
effusions.
When can an ICC be removed
for a pneumothorax?
• When there is no evidence of
an ongoing air leak combined
with complete resolution of the
pneumothorax on chest X-ray or
ultrasound.
• Suction if applied should be ceased
6–12 h prior to the chest X-ray.1
• After ICC removal the patient
should be observed for 2–6 h
with a repeat imaging prior to
discharge.1
67
• ICC removal may be performed
with breath-holding at end-
inspiration or end-expiration with
no difference in rate of recurrent
pneumothorax.14 Removal should be
rapid with immediate closure and
occlusion of the insertion site.
How should I decompress
a tension pneumothorax?
• Finger thoracostomy (FT) in the
triangle of safety is definitive
treatment.12 This is potentially life-
saving and also diagnostic as
to the true presence of a tension
pneumothorax.
• Needle thoracostomy does not re-
liably treat or exclude a tension
pneumothorax. This is irrespective
of both needle length and anterior
versus lateral approaches.15–18
Do I always have to follow
a FT with an ICC?
• Not always, and not immediately in
some contexts.
• If FT reveals:
• Massive haemothorax – follow it
with an ICC to accurately
assess blood loss and prevent
blood spillage.
• Pneumothorax:
• In spontaneously ventilating
patients follow by inserting an
ICC.
• In intubated and positive pres-
sure ventilated patients insert-
ing an ICC is not a time
critical priority and may be
safely delayed for transport to
hospital, the CT scanner or the
operating theatre if necessary.
The positive pressure prevents
the FT wound from becom-
ing an open sucking chest
wound.
• Negative for pneumothorax or
haemothorax:
• This is contentious. There are
no studies that directly address
this question.
• A FT does not injure the
underlying lung and visceral
pleura in the same way that
a negative needle thoracostomy
is likely to do so. The risk of
ongoing air leak is therefore
68
low if the lung was not injured
already. Theoretically, it would
be reasonable to close the FT
wound primarily in this
context, even in the setting of
ongoing positive pressure ven-
tilation. The experience of the
authors is that this might be
met with resistance from
surgical and anaesthetic
colleagues.
• A FT is a surgical incision and dis-
section – it is not the same as a trau-
matic penetrating chest wound. Use
the FT tract if an ICC is to be
placed, even if several hours elapse
before the ICC can be placed.
How should I secure the ICC?
• Chest drains should be secured with
1/0 silk suture anchored to the skin
and drain with a suitable non–slip
knot technique. The knot needs to
be tight around the drain. For small
drains, care needs to be taken not
to occlude the lumen when the knot
is tightened.
• The skin incision can be closed either
side of the ICC with non-absorbable,
monofilament, vertical mattress
sutures – usually 2-0 or 3-0 prolene
or nylon.
• Purse string sutures should be
avoided.18
• Large amounts of tape and padding
to dress the site are unnecessary and
might restrict chest wall move-
ment. Dressings should allow in-
spection of insertion site and drain
connections. Secure connections with
thin, longitudinal strips of tape.
Acknowledgement
The authors thank all the FACEMs in
the Townsville Hospital Emergency De-
partment who helped contribute with
their experience and suggestions.
Competing interests
BB and PK are section editors for
Emergency Medicine Australasia.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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