Pneumothorax, Iatrogenic


Article Author:
Jafet Ojeda Rodriguez


Article Editor:
John Hipskind


Editors In Chief:
Laurie Graham
Andrew Wilt
Mary Cataletto


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
6/18/2019 5:05:47 AM

Introduction

Pneumothorax is gas in the pleural space. This condition can present in one of three ways: spontaneous (primary), secondary, and traumatic. This activity focuses on a subset of traumatic pneumothoraces known as iatrogenic pneumothorax  This refers to a pneumothorax that has developed secondary to an invasive procedure such as pulmonary needle biopsy (transthoracic and transbronchial), placement of a central venous line or positive pressure ventilation.[1]  As a complication of one of these, a tension pneumothorax can develop when the pressure in the pleural space is positive throughout the respiratory cycle. This leads to decreased venous return, hypotension, and hypoxia. A pneumothorax can range from asymptomatic to potentially life-threatening. Iatrogenic pneumothorax is a patient safety indicator (PSI) of the above procedures.

Etiology

An iatrogenic pneumothorax is a known complication of invasive procedures such as pulmonary needle biopsy (transthoracic and transbronchial), placement of a central venous line, or positive pressure ventilation.[1] However, this condition can arise from many other procedures involving the thorax and abdomen. Case reports include bilateral pneumothoraces after incorrect placement of a nebulization kit in a spontaneously breathing intubated patient,[2] after insertion of a hypoglossal nerve stimulator,[3] or even after acupuncture.[4] Subclavian insertion of a central venous line (CVL), however, is the most common procedure associated with an iatrogenic pneumothorax.[5]

Epidemiology

The incidence of an iatrogenic pneumothorax is directly proportional to the number of invasive procedures performed.[6] Patients in unstable trauma or code situations are more likely to undergo an invasive intervention. This along with limited access to internal jugular sites when a non-femoral vein site is desired results in an elevated risk for iatrogenic pneumothorax.[5]

Pathophysiology

Any intervention in proximity to the abdomen, especially the thorax, can cause an iatrogenic pneumothorax. This is especially true when placing a subclavian central venous catheter without the use of ultrasound (i.e., "blindly") using landmarks.   In landmark-based subclavian central venous catheter placement, per Kilbourne et al.,[7] six common technical errors include inadequate landmark identification, improper insertion position, insertion of the needle through periosteum, taking too shallow a trajectory with the needle, aiming the needle too cephalad, and failure to keep the needle in place for wire passage. Landmark technique also depends on the ability and experience of the medical professional performing the procedure, making iatrogenic pneumothorax more likely in a tertiary teaching hospital.[8]

History and Physical

The presentation in a patient with a pneumothorax can range from asymptomatic to life-threatening based on the size, rate of development, and the health of the underlying lung. An iatrogenic pneumothorax is part of a differential diagnosis in a patient with pleuritic pain and dyspnea, tachypnea, and tachycardia. Decreased or absent breath sounds on the affected side is highly suspicious. Any pneumothorax can become a tension pneumothorax. Findings could include hypoxia, hypotension, distended neck veins, a displaced trachea, and unilaterally decreased breath sounds.[9] 

Evaluation

Iatrogenic pneumothorax can be diagnosed clinically. Point-of-care ultrasound has the advantage of being rapid, highly sensitive and specific, and easily repeatable. Suggestive findings include the lack of pleural sliding. A "point sign" (sliding pleural next to non-sliding pleura) is diagnostic. An upright posteroanterior chest radiography has 83% sensitivity.[9] Chest CT is more sensitive than chest radiography but inherently results in a delay in treatment.

Treatment / Management

First, determine if the patient is stable or unstable. Next, provide supplemental oxygen at a rate to maintain adequate oxygenation.[10] Some patients with small pneumothoraces may resolve with observation.[11] Definitive treatment options of a pneumothorax include needle aspiration, chest tube drainage, video-assisted thoracic surgery (VATS), and open surgical intervention.[12] Treatment takes precedence over imaging. If felt to be clinically unstable, the traditional first step is to perform a needle aspiration or decompression to reduce the excess air in the pleural space. Place a large-bore needle in the second intercostal space in the midclavicular line as a temporary measure.[13][14] Finger thoracostomy is the most recently used technique. One makes an incision over the lateral chest wall in the "safe triangle" formed by the lateral border of the pectoralis major, the lateral border of the latismus dorsi, the fifth intercostal space, and the base of the axilla. Next, one inserts a finger over the fifth intercostal space and bluntly dissects into the pleural space. It is fast and safe as it does not cause a pneumothorax and addresses the increasing girth of today's patients. Thoracostomy is the definitive therapy and uses the negative pressure generated by a water seal or suction to reduce air in the pleural space.[15] Chest tubes are inserted in either the second or third intercostal space of the midclavicular line (Monaldi position). They can also be inserted anterior to the mid-axillary line of the fourth or fifth intercostal space (Bulau position).[16] The other two treatment choices are purely surgical and reserved for severe cases.[17]

Differential Diagnosis

Although the diagnosis of pneumothorax should be definite and precise, a patient presenting with pleuritic pain without further management should elicit a robust differential diagnosis [10] such as:

  • Myocardial infarct
  • Myocardial ischemia
  • Pulmonary embolus
  • Pericarditis
  • Pleurisy
  • Pneumonia

Pertinent Studies and Ongoing Trials

Given that iatrogenic pneumothorax is a patient safety indicator (PSI) that is directly related to invasive procedures, most of the pertinent studies and ongoing trials focus on quality improvement and incidence reduction. Central venous catheter insertion is the main cause of iatrogenic pneumothoraces; so, patient factors (underlying condition, anatomy, restlessness, previous procedures), procedure decision-making (site, catheter type), and clinical factors are given particular consideration for improvement of outcomes.[18] Another quality improvement observational study in a tertiary care hospital demonstrated improvement and a sustained reduction of iatrogenic cases through a multifaceted intervention. This consisted of clinical and documentation standardization, the addition of cognitive aids, simulator training, use of ultrasound equipment, and feedback to clinical services.[5] Other studies have linked physicians-in-training to worse outcomes due to lack of experience[8]; however, simulation-based mastery has shown to improve patient outcomes.[19]

Prognosis

The estimated risk of pneumothorax recurrence is 23% to 50% over a 1- to 5-year follow-up period, with the highest risk during the first month.[20] However, there is no data for recurrence or incidence changes specific to iatrogenic pneumothoraces. In patients who underwent tube thoracostomy, it is safe for them to fly as early as 72 hours after tube removal without increased risk of recurrence.[21]

Complications

Tension pneumothorax is the most notable complication of any pneumothorax previously described. This disorder is life-threatening and requires immediate intervention.[22] Another well-described complication of pneumothorax is having a persistent air leak and/or failure of lung re-expansion, which usually require further surgical intervention.[23]

Deterrence and Patient Education

A pneumothorax, also known as a collapsed lung, occurs when air (either from the lung or outside) collects in the space between the lung and the chest wall. The focus of this article is the specific cause of a collapsed lung, called iatrogenic or caused accidentally during surgery or a procedure. Symptoms of a collapsed are a sharp or stabbing chest pain and/or trouble breathing. People with small amounts of air may not have any symptoms at all. This condition can be an emergency and require immediate treatment. Treatment involves extracting the air trapped between the lung and the chest wall by either a needle, scalpel and finger, or chest tube. Regardless, a chest tube is inserted and stays in place until the lung expands to its normal size. Some individuals with severe cases may require surgery. After being treated for a collapsed lung with a tube, chances of having a recurrence is low but possible. Patients should avoid scuba diving and flying in a plane for at least 72 hours.[24]

Pearls and Other Issues

  • Iatrogenic pneumothorax is a patient safety indicator (PSI) condition.  It is a traumatic pneumothorax secondary to an invasive procedure or surgery.
  • The most common cause is the placement of a subclavian central venous line (CVL).
  • Other causes include pulmonary needle biopsy (transthoracic and transbronchial), nasogastric tube placement, or positive pressure ventilation. There are case reports after placing nebulizer kits and acupuncture to the chest wall.
  • The presentation is mainly pleuritic chest pain and dyspnea with decreased to absent breath sounds on the affected side during or after a procedure.
  • Treatment should not be delayed for imaging.
  • The diagnosis is ideally made clinically. Ultrasound evaluation to check for pneumothorax is emerging as a very accurate and rapid tool.
  • Treatment is needle decompression followed by tube thoracostomy. VATS and open thoracotomy are reserved for recurrent or severe cases.

Enhancing Healthcare Team Outcomes

Iatrogenic pneumothorax is an important PSI condition associated with morbidity and mortality. Iatrogenic pneumothoraces are attributed to procedure techniques/decision-making pitfalls, medical provider experience, and not using ultrasound during CVC placement.[25] (Level V) Recent systematic reviews have focused on the role of simulation-based education addressing all the common causes. This training results in the improvement of CVC techniques and reduction of iatrogenic pneumothorax cases.[26][27][28] (Level I) In an academic tertiary care hospital, an interprofessional team including physicians, nurses, and administrative leaders improved and sustained a reduction in iatrogenic pneumothoraces. This was done by implementing clinical documentation standards, cognitive aids, simulation training, purchase/employment of ultrasound equipment, and feedback to clinical services.[5] (Level I) The role of interprofessional communication and care coordination between health professionals cannot be understated when considering patient outcomes.


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Pneumothorax, Iatrogenic - Questions

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A patient who suffered a multiorgan injury is intubated in the intensive care unit. His ventilator settings rate is 14, FiO2 60%, total volume 450 ml, and positive end-expiratory pressure of 12. At night, the nurse notices a significant amount of subcutaneous emphysema and elevated peak pressures. What should be the next step in the management of this patient?



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A patient is having a mediastinoscopy. No significant lymph nodes are visible, and the procedure is continued. There is continued aspiration and probing with the needle. The anesthesia provider mentions that the patient is hypotensive and hypoxic. Which of the following has occurred?



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A 60-year-old man was admitted to the ICU after an automobile accident. On admission, he was hemodynamically stable, and his Glasgow Coma Score was 8. He was intubated, and CT scanning of the head revealed multiple foci of contusion associated with subarachnoid hemorrhage. His course in the ICU was characterized by a slow improvement in neurologic function. Because he required long-term mechanical ventilatory support, percutaneous dilational tracheostomy (PDT) was performed. The initial puncture and dilatations were made without difficulty. However, the larger dilators and the tracheostomy tube appeared to pass through the stoma with some resistance. After the tracheostomy tube was in place, diminished breath sounds were noted on the right side and pulse oximeter readings declined rapidly. What is the most appropriate treatment for this patient?



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A 67-year-old patient with chronic obstructive pulmonary disease is on mechanical ventilation with the following settings: assist-control (AC) 12, tidal volume (TV) 650, positive end-expiratory pressure (PEEP) 10, and FiO2 40%. The patient suddenly develops desaturation to 75% and becomes hypotensive, diaphoretic, and tachycardic. What is the definitive management for this patient?



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What is a common cause of iatrogenic pneumothorax?



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Which of the following can be an adverse effect of elevated positive end-expiratory pressure (PEEP) in mechanically ventilated patients?



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Which of the following is the most common cause of iatrogenic pneumothorax in an adult patient?



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A 36-year-old, small frame female is brought to the emergency department from the holistic medicine clinic for pleuritic chest pain, diaphoresis, and dyspnea. She currently smokes 1 pack of cigarettes per day and had a recent upper respiratory tract infection. She also has chronic thoracic back pain treated by a chiropractor and acupuncturist. On exam, she has decreased breath sounds in the left lung on auscultation. What is the most likely cause of her symptoms?



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A 71-year-old male reports chest pain and shortness of breath during a right subclavian central venous catheter placement. After halting the procedure, you discover absent right-sided lung sounds. His vitals are stable with mild tachypnea. What is the first step in the management of this patient?



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Pneumothorax, Iatrogenic - References

References

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