Iatrogenic Pneumothorax

Iatrogenic pneumothorax occurs more than spontaneous pneumothorax and is a subset of traumatic penetrating pneumothorax. Transthoracic needle procedures (transthoracic needle biopsy and thoracentesis) account for more than 50 percent of cases, and subclavian vein catheterization accounts for 22 percent. 18 Given that one central venous line is placed every minute in the United States, and pneumothorax occurs after 1 to 12 percent of subclavian line attempts, iatrogenic pneumothorax must be common.1 19 and 20 Some of the factors increasing the frequency of iatrogenic pneumothorax include the patient population, underlying disease, body habitus, and experience of the operator.18 Ultrasound guidance for thoracentesis has been shown to reduce the pneumothorax complication rate from 18 to 3 percent21 and appears promising to reduce the incidence of pneumothorax with central venous line placement.22

Chest radiograph is standard after central line placement or transthoracic needle procedures, but may miss an iatrogenic pneumothorax because of the use of a supine technique or inadequate time for the pneumothorax to develop. Delayed pneumothoraces are common after subclavian line placement; up to 4 percent are delayed for up to 96 h.23 Emergency department experience with other penetrating chest trauma recognizes the risk of delayed pneumothorax of up to 6 h. 24

Treatment for iatrogenic pneumothorax parallels that for spontaneous pneumothorax, with some important caveats. Patients on mechanical ventilation require large-bore chest tube thoracostomy.20 Conversely, patients sustaining a small pneumothorax after a needle puncture and not receiving positive pressure ventilation can be initially treated with simple catheter aspiration, which will be adequate in up to 60 percent of patients. These patients need to be admitted to the hospital, with the catheter in place for observation, because prolonged air leak may occur in some patients. 25 Recurrence is not an issue in these patients, but deaths have occurred from iatrogenic pneumothorax.20

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