Iatrogenic pneumothorax

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Background

Causes[1]

  • Transthoracic needle aspiration (24%)
  • Subclavian vessel puncture (22%)
  • Thoracentesis (22%)
  • Pleural biopsy (8%)
  • Mechanical ventilation (7%)

Clinical Features

Consider in all patients with sudden deterioration after intubation

  • Sudden onset pleuritic chest pain
  • Tachypnea, hypoxemia, increased work of breathing
  • Reduced ipsilateral lung excursion
  • Hypotension → tension pneumothorax

Differential Diagnosis

Pneumothorax Types

Evaluation

Clinically Stable

Defined as having all of the following:

  • Resp rate < 24
  • Heart rate 60-120 beats per minute
  • Normal BP
  • SaO2 >90% on room air and patient can speak in whole sentences

Workup

Pneumothorax.jpeg
  • CXR
    • Displaced visceral pleural line without lung markings between pleural line and chest wall
    • Upright is best
      • Expiratory films DO NOT improve accuracy[2]
    • Supine CXR = deep sulcus sign
  • CT Chest
    • Very sensitive and specific
  • Ultrasound
    • NO comet tail artifact
    • No sliding lung sign
    • Bar Code appearance on M-mode (absence of "seashore" waves)

Management

Supplemental oxygen (non-rebreather mask) initially for all

Unstable

Stable[1]

Not on Positive Pressure

  • Observation (majority) vs. aspiration
  • Chest tube if become symptomatic

On Positive Pressure Ventilation

Needle Aspiration of Pneumothorax

  • Use thoracentesis or "pig-tail" kit, if available
  • Place in 2nd IC space in midclavicular line or 4th/5th IC space in anterior axillary line
  • Withdraw air with syringe until no more can be aspirated
    • Assume a persistent air leak (failure) if no resistance after 4 liters of air has been aspirated AND the lung has not expanded
  • Once no further air can be aspirated:
    • Option 1
      • Place closed stopcock and secure catheter to the chest wall
      • Obtain CXR four hours later
      • If adequate lung expansion has occurred, remove catheter
      • Following another two hours of observation, obtain another CXR
      • If the lung remains expanded, may discharge patient
    • Option 2
      • Leave catheter in place
      • Attached a Heimlich (one-way) valve
      • May discharge with follow-up within two days

Adult Chest Tube Sizes

Chest Tube Size Type of Patient Underlying Causes
Small (8-14 Fr)
  • Alveolar-pleural fistulae (small air leak)
  • Iatrogenic air
Medium (20-28 Fr)
  • Bronchial-pleural fistulae (large air leak)
  • Malignant fluid
Large (36-40 Fr)
  • Bleeding (Hemothorax/hemopneumothorax)
  • Thick pus

Disposition

  • See Management section

See Also

External Links

References

  1. 1.0 1.1 "Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010." Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 PDF
  2. Eur Respir J. 1996 Mar;9(3):406-9