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POCUS for Pediatric Chest Tube – Is Fifth ICS Too Low?

June 21, 2024

Written by Megan Hilbert

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Reliance on landmark guidance for chest tube placement may pose significant safety issues in pediatric patients.

Scan that chest before you do the rest!
Previous literature has demonstrated that landmark guided placement of chest tubes in the fifth intercostal space (ICS) may not always be safe in adults. This observational study examined the safety of landmark guidance in 150 pediatric patients (50 in each age group: 1-5, 6-12, and 13-17 years). The primary aim was to use an ultrasound to determine the percentage of patients where this approach would be deemed “unsafe,” defined as visualization of the diaphragm crossing the superior margin of the sixth rib during either tidal respiration or maximal respiration while completing a point-of-care ultrasound. See figure. Left is safe; right is unsafe.

safe vs unsafe chest ultrasound of pediatric patient, fifth intercostal space
From cited article

The authors found that the diaphragm crossed this space 10.3% (95%CI 6.45-16.1) of the time during tidal respirations and 27.2% (95%CI 19.0-37.3) of the time during maximal respiration. Secondary analysis (univariate and multivariate) determined that this was more likely to occur on the right side of the body (45.0%, 95%CI 36.1-54.3) as well as in individuals with a higher BMI (increase of 10% or more with each additional 1-kg/m2; P=0.003).

While there are specific concerns with pediatric patients (such as anatomical differences, i.e. abdominal organ size), these findings are mostly consistent with adult data. This was a convenience sample and did not evaluate safety in children < 1 year of age. Having said that, it’s a well done observational study that highlights an important concern that necessitates further investigation in the future.

How will this change my practice?
Doing a procedure on a pediatric patient can be nerve-wracking. Any additional safety measure that I can undertake to improve my success and limit potential complications is definitely something I am willing to do. So, next time I consider a chest tube on a pediatric patient you can bet that I am going to throw a probe on their chest and make sure my approach is as safe as it can be.

Ultrasound Investigation of the Fifth Intercostal Space Landmark for Chest Tube Thoracostomy Site Selection in Pediatric Patients. Pediatr Emerg Care. 2024 Apr 23. doi: 10.1097/PEC.0000000000003207. Epub ahead of print. PMID: 38713844.

What are your thoughts?