Continuing Education Activity

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. Pneumothorax can present in 1 of 3 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 a pulmonary needle biopsy (transthoracic and transbronchial), a central venous line placement, or positive pressure ventilation.

Iatrogenic pneumothorax is an important PSI condition associated with morbidity and mortality. To reduce the rate of iatrogenic pneumothorax, healthcare providers must implement standardized protocols, enhance training and competency assessment, improve communication and documentation, allocate appropriate resources and equipment, and integrate quality improvement initiatives. By fostering a safety culture and implementing evidence-based practices, healthcare systems can mitigate the risk of iatrogenic pneumothorax and improve patient outcomes.

This activity discusses the need to prioritize the cautious insertion of medical devices to mitigate the risk of iatrogenic pneumothorax. An evidence-based management algorithm for iatrogenic pneumothorax is provided for management steps and strategies. Collaboration within an interprofessional team is imperative to cultivate a safety culture and mitigate the risk of iatrogenic pneumothorax. This course emphasizes a shared responsibility for patient safety to proactively address risk factors, implement preventive measures, and collectively strive for optimal patient outcomes.

Objectives:

• Apply the pathophysiology of pneumothorax and point-of-care ultrasound or other imaging during diagnostic strategies.

• Improve processes to prioritize the cautious insertion of medical devices to mitigate the risk of iatrogenic pneumothorax.

• Implement an evidence-based management algorithm for iatrogenic pneumothorax.

• Collaborate with the interprofessional team to develop strategies for fostering a safety culture that will mitigate the risk of iatrogenic pneumothorax.

Introduction

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. This condition can present in 1 of 3 ways: spontaneous (primary), secondary, and traumatic. This activity focuses on a subset of traumatic pneumothoraces known as iatrogenic pneumothorax. This refers to a pneumothorax developed secondary to an invasive procedure such as a pulmonary needle biopsy (transthoracic and transbronchial), a central venous line placement, or positive pressure ventilation.[1] As a complication of an invasive procedure, 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 thorax and abdomen procedures. 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] However, subclavian insertion of a central venous line (CVL) 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 nonfemoral 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 ultrasound (ie, "blindly") using landmarks. In landmark-based subclavian central venous catheter placement, per Kilbourne et al,[7] 6 common technical errors include inadequate landmark identification, improper insertion position, insertion of the needle through periosteum, too shallow a trajectory with the needle, the needle aim being 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 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 are 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, specific, and easily repeatable. Suggestive findings include the lack of pleural sliding. A "point sign" (sliding pleural next to nonsliding pleura) is diagnostic. Upright posteroanterior chest radiography has 83% sensitivity (see Image. Left Pneumothorax on X-ray).[9] Chest CT is more sensitive than chest radiography but inherently results in a delay in treatment (see Image. CT Scan, Pneumothorax).

Treatment / Management

First, determine if the patient is stable or unstable. Next, supplemental oxygen at a rate that maintains adequate oxygenation is provided.[10] Some patients with small pneumothoraces may resolve with observation.[11] Definitive treatment options for 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. As a temporary measure, place a large-bore needle in the second intercostal space in the midclavicular line.[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 latissimus 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 the midclavicular line's second or third intercostal space (Monaldi position). Chest tubes can also be inserted anterior to the midaxillary line of the fourth or fifth intercostal space (Bulau position).[16] The other 2 treatment choices are purely surgical and reserved for severe cases.[17]

Management Algorithm for Iatrogenic Pneumothorax

1. Assessment of patient stability: Determine if the patient is stable or unstable. If unstable, proceed to immediate needle decompression.

2. Oxygenation: Provide supplemental oxygen at a rate to maintain adequate oxygenation.

3. Observation for small pneumothoraces: Some patients with small pneumothoraces may resolve with observation.

4. Definitive treatment options:

   • Needle aspiration
   • Chest tube drainage
   • VATS
   • Open surgical intervention

5. Prioritization of treatment over imaging: Treatment takes precedence over imaging.

6. Initial management for clinically unstable patients: Perform needle aspiration or decompression to reduce excess air in the pleural space. As a temporary measure, place a large-bore needle in the second intercostal space in the midclavicular line.

7. Finger thoracostomy: If finger thoracostomy is needed, make 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 latissimus dorsi, the fifth intercostal space, and the base of the axilla. Insert a finger over the fifth intercostal space and bluntly dissect into the pleural space.

8. Definitive therapy: Thoracostomy is definitive therapy. Use negative pressure from a water seal or suction to reduce air in the pleural space. Chest tubes are inserted in either the second or third intercostal space of the midclavicular line (Monaldi position) or anterior to the mid-axillary line of the fourth or fifth intercostal space (Bulau position).

9. Surgical intervention: Surgical interventions for severe cases are VATS and open surgical intervention.

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 such as one of the following:

• Myocardial infarct
• Myocardial ischemia
• Pulmonary embolus
• Pericarditis
• Pleurisy
• Pneumonia [10]

Pertinent Studies and Ongoing Trials

Given that iatrogenic pneumothorax is a 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. Therefore, patient factors (eg, underlying condition, anatomy, restlessness, previous procedures), procedure decision-making factors (eg, site or catheter type), and clinical factors influence outcomes.[18] 

A 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, the 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 improved 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, no data for recurrence or incidence changes specific to iatrogenic pneumothoraces exists. In patients who underwent tube thoracostomy, it is safe 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 failure of lung re-expansion, which usually requires 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. A collapsed lung caused accidentally during a procedure is called an iatrogenic pneumothorax. Symptoms of a collapsed lung include sharp or stabbing chest pain and trouble breathing. People with small amounts of trapped air may not have any symptoms.

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, finger, or chest tube. Regardless, an inserted chest tube 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, the chances of having a recurrence are low but possible. Patients should avoid scuba diving and flying in a plane for at least 72 hours.[24]

Pearls and Other Issues

Key facts to keep in mind regarding iatrogenic pneumothorax are as follows:

• Iatrogenic pneumothorax is a PSI condition. It is a traumatic pneumothorax secondary to an invasive procedure or surgery.
• The most common cause is a subclavian central venous line placement.
• 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 on 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 suboptimal procedure techniques/decision-making pitfalls, lack of medical provider experience, and lack of ultrasound use during CVC placement.[25] Clinicians should prioritize the cautious insertion of medical devices, such as central venous catheters and chest tubes, to mitigate the risk of iatrogenic pneumothorax—a potentially serious complication. Clinicians should utilize imaging guidance, like ultrasound, to enhance precision during procedures, avoiding inadvertent lung puncture. The proper technique and regular reassessment of needle or tube placement minimize complications. A high level of awareness for patient-specific factors, such as underlying lung conditions, that may increase susceptibility should be maintained. Adherence to stringent aseptic practices and ongoing education on best practices are crucial for preventing iatrogenic pneumothorax in clinical settings.

In managing iatrogenic pneumothorax, clinicians should promptly recognize symptoms, including respiratory distress and chest pain. The diagnosis should be confirmed and the severity of the condition gauged through imaging (eg, chest x-ray). Small, asymptomatic cases may resolve spontaneously, but more significant or symptomatic pneumothoraces require intervention. Clinicians should opt for conservative measures like observation or supplemental oxygen if the pneumothorax is minor. Needle aspiration or chest tube insertion to evacuate air and re-establish lung expansion should be considered for more severe cases. Clinicians should regularly reassess the patient's respiratory status and adjust treatment accordingly, ensuring a tailored approach for optimal recovery.

Collaboration within an interprofessional team is imperative to cultivate a safety culture and mitigate the risk of iatrogenic pneumothorax. Clear communication among physicians, advanced practitioners, nurses, and specialists ensures comprehensive patient assessment, minimizing procedural errors. Regular interdisciplinary training promotes standardized protocols and enhances collective awareness of potential complications. 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 the reduction of iatrogenic pneumothorax cases.[26][27][28] 

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 performed by implementing clinical documentation standards, cognitive aids, simulation training, purchase/employment of ultrasound equipment, and feedback to clinical services.[5] The role of interprofessional communication and care coordination between health professionals cannot be understated when considering patient outcomes.

Emphasizing a shared responsibility for patient safety encourages open dialogue, enabling quick identification and resolution of issues. By fostering a collaborative approach, healthcare teams can proactively address risk factors, implement preventive measures, and collectively strive for optimal patient outcomes, reducing the incidence of iatrogenic pneumothorax in clinical settings.