Needle biopsy of pleural and pulmonary lesions is usually undertaken using image guidance. However, every doctor should be able to aspirate a chest.

This is particularly so for a tension pneumothorax: use a syringe and insert the needle through the second intercostal space, in the midclavicular line (figure 33a). If formal drainage is required, insert a cannula through the fourth intercostals space, in the midaxillary line (figure 33b).

When time allows, the procedures should use sterile techniques and local anesthesia down to the parietal pleura; a two-way tap is needed for the needle. The main neurovascular bundle passes just under the lower border of each rib, insertion is therefore above or between the ribs. An under-water seal is required for continued drainage.


Fluid drainage, such as an effusion or a hematoma, is usually undertaken posteriorly, through the seventh intercostal space (the level of the lower border of the scapula), but it may also be in the midaxillary line, through the fourth or fifth intercostal space (figure 34a,b). Access is improved posteriorly by placing the elbows forwards, and in the axilla by raising the patient’s arm.