Pneumothorax, Iatrogenic

Article Author:
Jafet Ojeda Rodriguez
Article Editor:
John Hipskind
Updated:
6/18/2019 5:05:47 AM
PubMed Link:
Pneumothorax, Iatrogenic

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.


References

[1] Loiselle A,Parish JM,Wilkens JA,Jaroszewski DE, Managing iatrogenic pneumothorax and chest tubes. Journal of hospital medicine. 2013 Jul     [PubMed PMID: 23765922]
[2] Garg SK,Garg P,Anchan N,Jaiswal A, Iatrogenic Bilateral Simultaneous Pneumothorax: Call for Vigilance. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine. 2017 Sep     [PubMed PMID: 28970663]
[3] Arteaga AA,Pitts KD,Lewis AF, Iatrogenic pneumothorax during hypoglossal nerve stimulator implantation. American journal of otolaryngology. 2018 Jun 14     [PubMed PMID: 29941192]
[4] Tagami R,Moriya T,Kinoshita K,Tanjoh K, Bilateral tension pneumothorax related to acupuncture. Acupuncture in medicine : journal of the British Medical Acupuncture Society. 2013 Jun     [PubMed PMID: 23449179]
[5] Shieh L,Go M,Gessner D,Chen JH,Hopkins J,Maggio P, Improving and sustaining a reduction in iatrogenic pneumothorax through a multifaceted quality-improvement approach. Journal of hospital medicine. 2015 Sep     [PubMed PMID: 26041246]
[6] Celik B,Sahin E,Nadir A,Kaptanoglu M, Iatrogenic pneumothorax: etiology, incidence and risk factors. The Thoracic and cardiovascular surgeon. 2009 Aug     [PubMed PMID: 19629891]
[7] Kilbourne MJ,Bochicchio GV,Scalea T,Xiao Y, Avoiding common technical errors in subclavian central venous catheter placement. Journal of the American College of Surgeons. 2009 Jan     [PubMed PMID: 19228511]
[8] John J,Seifi A, Incidence of iatrogenic pneumothorax in the United States in teaching vs. non-teaching hospitals from 2000 to 2012. Journal of critical care. 2016 Aug     [PubMed PMID: 27288612]
[9] Swierzy M,Helmig M,Ismail M,R�ckert J,Walles T,Neudecker J, [Pneumothorax]. Zentralblatt fur Chirurgie. 2014 Sep     [PubMed PMID: 25264729]
[10] Haynes D,Baumann MH, Management of pneumothorax. Seminars in respiratory and critical care medicine. 2010 Dec     [PubMed PMID: 21213209]
[11] Hefny AF,Kunhivalappil FT,Matev N,Avila NA,Bashir MO,Abu-Zidan FM, Management of computed tomography-detected pneumothorax in patients with blunt trauma: experience from a community-based hospital. Singapore medical journal. 2018 Mar     [PubMed PMID: 28741012]
[12] Tupchong K, Update: Is Needle Aspiration Better Than Chest Tube Placement for the Management of Primary Spontaneous Pneumothorax? Annals of emergency medicine. 2018 Jul     [PubMed PMID: 29615265]
[13] Bruschettini M,Romantsik O,Ramenghi LA,Zappettini S,O'Donnell CP,Calevo MG, Needle aspiration versus intercostal tube drainage for pneumothorax in the newborn. The Cochrane database of systematic reviews. 2016 Jan 11     [PubMed PMID: 26751585]
[14] Naik ND,Hernandez MC,Anderson JR,Ross EK,Zielinski MD,Aho JM, Needle Decompression of Tension Pneumothorax with Colorimetric Capnography. Chest. 2017 Nov     [PubMed PMID: 28499514]
[15] Wang C,Lyu M,Zhou J,Liu Y,Ji Y, Chest tube drainage versus needle aspiration for primary spontaneous pneumothorax: which is better? Journal of thoracic disease. 2017 Oct     [PubMed PMID: 29268413]
[16] Drinhaus H,Annecke T,Hinkelbein J, [Chest decompression in emergency medicine and intensive care]. Der Anaesthesist. 2016 Oct     [PubMed PMID: 27629501]
[17] Delpy JP,Pag�s PB,Mordant P,Falcoz PE,Thomas P,Le Pimpec-Barthes F,Dahan M,Bernard A, Surgical management of spontaneous pneumothorax: are there any prognostic factors influencing postoperative complications? European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2016 Mar     [PubMed PMID: 26071433]
[18] Tsotsolis N,Tsirgogianni K,Kioumis I,Pitsiou G,Baka S,Papaiwannou A,Karavergou A,Rapti A,Trakada G,Katsikogiannis N,Tsakiridis K,Karapantzos I,Karapantzou C,Barbetakis N,Zissimopoulos A,Kuhajda I,Andjelkovic D,Zarogoulidis K,Zarogoulidis P, Pneumothorax as a complication of central venous catheter insertion. Annals of translational medicine. 2015 Mar     [PubMed PMID: 25815301]
[19] Barsuk JH,Cohen ER,Williams MV,Scher J,Jones SF,Feinglass J,McGaghie WC,O'Hara K,Wayne DB, Simulation-Based Mastery Learning for Thoracentesis Skills Improves Patient Outcomes: A Randomized Trial. Academic medicine : journal of the Association of American Medical Colleges. 2018 May     [PubMed PMID: 29068818]
[20] Baumann MH,Strange C,Heffner JE,Light R,Kirby TJ,Klein J,Luketich JD,Panacek EA,Sahn SA, Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001 Feb     [PubMed PMID: 11171742]
[21] Zonies D,Elterman J,Burns C,Paul V,Oh J,Cannon J, Trauma patients are safe to fly 72 hours after tube thoracostomy removal. The journal of trauma and acute care surgery. 2018 May 18     [PubMed PMID: 29782482]
[22] Roberts DJ,Leigh-Smith S,Faris PD,Blackmore C,Ball CG,Robertson HL,Dixon E,James MT,Kirkpatrick AW,Kortbeek JB,Stelfox HT, Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review. Annals of surgery. 2015 Jun     [PubMed PMID: 25563887]
[23] Slade M, Management of pneumothorax and prolonged air leak. Seminars in respiratory and critical care medicine. 2014 Dec     [PubMed PMID: 25463161]
[24] Imran JB,Eastman AL, Pneumothorax. JAMA. 2017 Sep 12     [PubMed PMID: 28898380]
[25] Giacomini M,Iapichino G,Armani S,Cozzolino M,Brancaccio D,Gallieni M, How to avoid and manage a pneumothorax. The journal of vascular access. 2006 Jan-Mar     [PubMed PMID: 16596523]
[26] Soffler MI,Hayes MM,Smith CC, Central venous catheterization training: current perspectives on the role of simulation. Advances in medical education and practice. 2018     [PubMed PMID: 29872360]
[27] Ma IW,Brindle ME,Ronksley PE,Lorenzetti DL,Sauve RS,Ghali WA, Use of simulation-based education to improve outcomes of central venous catheterization: a systematic review and meta-analysis. Academic medicine : journal of the Association of American Medical Colleges. 2011 Sep     [PubMed PMID: 21785310]
[28] Sekiguchi H,Tokita JE,Minami T,Eisen LA,Mayo PH,Narasimhan M, A prerotational, simulation-based workshop improves the safety of central venous catheter insertion: results of a successful internal medicine house staff training program. Chest. 2011 Sep     [PubMed PMID: 21659429]