Paeds · investigations-procedures-and-technology
Chest decompression and intercostal drain insertion
Also known as Needle thoracostomy · Needle decompression · Intercostal catheter insertion · Chest drain insertion · Intercostal drain · Chest tube · Underwater seal drainage
A fellowship approach to chest decompression and intercostal drain insertion in children covering tension pneumothorax as a clinical diagnosis requiring immediate needle decompression at the second intercostal space mid-clavicular line or the fourth or fifth intercostal space at the anterior axillary line within the safe triangle, the safe triangle boundaries (anterior border lateral edge of pectoralis major, posterior border lateral edge of latissimus dorsi, inferior border the fifth intercostal space at the nipple line, apex at the base of the axilla), the rule of inserting above the rib below to avoid the neurovascular bundle that runs in the costal groove along the inferior border of the rib above, the stepwise blunt-dissection drain insertion technique, drain-size selection by content (small-bore 8 to 14 French pigtail for air, medium 16 to 24 French for fluid and empyema, large-bore 28 to 36 French for blood), the underwater seal with the tube tip two centimetres below the water line, the lidocaine 1 per cent maximum three milligrams per kilogram dose, the never-clamp-a-bubbling-drain rule, the complications of bleeding from the intercostal vessels, re-expansion pulmonary oedema, and wrong-side insertion, and the special scenarios of the ventilated neonate, adolescent spontaneous pneumothorax, and complicated parapneumonic empyema with intrapleural fibrinolytics.
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Target exams
Red flags
- A child in respiratory distress with hypoxia, reduced air entry, and circulatory collapse has a tension pneumothorax until proved otherwise — decompress now, do not wait for a chest radiograph
- A ventilated child (especially a neonate) who suddenly deteriorates with rising airway pressures and falling oxygen saturations — tension pneumothorax is the diagnosis to exclude first
- Clamping a bubbling chest drain — this converts a communicating pneumothorax back into a life-threatening tension pneumothorax
- Draining a very large pleural effusion too quickly — risk of re-expansion pulmonary oedema; pause and reassess after roughly 1.5 litres
- Inserting a drain through the wrong intercostal space or on the wrong side — a never-event; use a pre-procedure pause and, where time allows, a confirmatory chest radiograph
- Inserting below a rib rather than above it — the intercostal neurovascular bundle runs in the costal groove along the inferior border of the rib above and will bleed
- Needle decompression at the second intercostal space mid-clavicular line that is too short to reach the pleural space — suspect failure if the child does not improve and re-decompress at the anterior axillary line
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Recognition and management of the acutely ill or injured child
- Procedural skills — needle decompression and intercostal drain insertion
- Emergency, trauma and resuscitation medicine
- Current 2026 PREP curriculum — Procedural skills in the acutely ill or injured child
- Clinical Applications
- Medical Sciences
- Procedural skills
- Short Cases
- Structured oral — acutely ill or injured child
- 1.4 Safely and appropriately performs practical procedures and uses medical devices
- 4. Patient management
- 8. Patient safety
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Clinical — structured oral and procedural safety in an emergency
- General Pediatrics Content Outline — Emergency Medicine, Critical Care; Procedural skills
- Universal Task 4: Management and Treatment
- Patient Care 1: procedural competency
- Systems-Based Practice
- Medical Expert
- Collaborator
- Pediatrics: Procedural skill — chest decompression and intercostal drain insertion
Overview & Definition
Picture a six-year-old hit by a car, now on a ventilator in the emergency department. Half a minute ago he was stable; now his oxygen saturations are crashing, his airway pressure alarm is shrieking, his blood pressure is falling, and the right side of his chest is silent and hyperresonant. Every second you spend confirming what you already know is a second his heart goes without venous return. Chest decompression exists for exactly this moment: to let the trapped air out of the pleural space before it kills him. [3] [10]
Two procedures live under this single topic, and the candidate must hold them apart. Needle thoracostomy (needle decompression) is the emergency, temporary act of pushing a cannula through the chest wall to vent a suspected tension pneumothorax. Intercostal drain (chest tube, ICC) insertion is the definitive act of placing a tube into the pleural space and connecting it to an underwater seal that lets air and fluid out while stopping air going back in. Needle decompression buys minutes; the intercostal drain buys the hours to days the lung needs to heal. A child who needed a needle will need a drain; a child who needs a drain does not always need a needle. [1]
A third, gentler cousin is pleural aspiration (thoracentesis) — draining fluid from the pleural space with a needle or cannula for diagnosis or symptom relief. It uses the same landmarks and the same respect for the neurovascular bundle, but it is not the emergency procedure and it is not what tension pneumothorax is treated with. Throughout this topic the focus is the two emergency procedures, with aspiration appearing where the differential and the technique overlap. [1]
References12ShowHide
- [1]Roberts ME, Rahman NM, Maskell NA, et al British Thoracic Society Guideline for pleural disease Thorax, 2023.PMID 37553157
- [2]Balfour-Lynn IM, Abrahamson E, Cohen G, et al BTS guidelines for the management of pleural infection in children Thorax, 2005.PMID 15681514
- [3]Lyng JW, Ward C, Angelidis M, et al Prehospital Trauma Compendium: Traumatic Pneumothorax Care. Position Statement and Resource Document of NAEMSP Prehospital Emergency Care, 2024.PMID 39499620
- [4]Ahmad SJS, Degiannis JR, Head M, et al Meta-analysis of the optimal needle length and decompression site for tension pneumothorax and consensus recommendations on current ATLS and ETC guidelines World Journal of Emergency Surgery, 2025.PMID 40383767
- [5]Terboven T, Heblich LA, Weiss C, et al The nipple as a landmark for needle decompression of tension pneumothorax in children: a CT-based evaluation and proposal of an alternative insertion site Prehospital Emergency Care, 2021.PMID 33026282
- [6]Terboven T, Leonhard G, Wessel L, et al Chest wall thickness and depth to vital structures in paediatric patients: implications for prehospital needle decompression of tension pneumothorax Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2019.PMID 30992028
- [7]Hossain R, Qadri U, Dembowski N, et al Sound and air: ultrasonographic measurements of pediatric chest wall thickness and implications for needle decompression of tension pneumothorax Pediatric Emergency Care, 2021.PMID 32925707
- [8]Speck KE, Kulaylat AN, Baerg JE, et al Evaluation and management of primary spontaneous pneumothorax in adolescents and young adults: a systematic review from the APSA Outcomes and Evidence-Based Practice Committee Journal of Pediatric Surgery, 2023.PMID 37130765
- [9]Bruschettini M, Romantsik O, Zappettini S, et al Needle aspiration versus intercostal tube drainage for pneumothorax in the newborn Cochrane Database of Systematic Reviews, 2019.PMID 30707441
- [10]Boever JC, Ott MJ, Muldiiarov V, et al Prehospital needle thoracostomy and the need to implement objective criteria for intervention: a retrospective study Injury, 2026.PMID 41436345
- [11]Beyer CA, Byrne JP, Moore SA, et al Predictors of initial management failure in traumatic hemothorax: a prospective multicenter cohort analysis Surgery, 2023.PMID 37500410
- [12]Kaur D, Kumar K, Mishra P, et al Early versus late(r) administration of intrapleural fibrinolytic therapy in children with empyema: a systematic review and meta-analysis Indian Pediatrics, 2026.PMID 42430023