Managing iatrogenic pneumothorax and chest tubes

Chest tube placement incidence when using gelatin sponge torpedoes after pulmonary radiofrequency ablation

Purpose

To assess the efficacy of the gelatin torpedoes embolization technique after lung neoplastic lesions percutaneous radiofrequency ablation (PRFA) to reduce chest tube placement rate and hospital length of stay, and the safety of this embolization technique.

Materials and methods

A total of 114 PRFA of lung neoplastic lesions performed in two centers between January 2017 and December 2022 were retrospectively reviewed. Two groups were compared, with 42 PRFA with gelatin torpedoes embolization technique (gelatin group) and 72 procedures without (control group). Procedures were performed by one of seven interventional radiologists using LeVeen CoAccess™ probe. Multivariate analyses were performed to identify risk factors for chest tube placement and hospital length of stay.

Results

There was a significantly lower chest tube placement rate in the gelatin group compared to the control group (3 [7.1 %] vs. 27 [37.5 %], p < 0,001). Multivariate analysis showed a significant association between chest tube placement and gelatin torpedoes embolization technique (OR: 0.09; 95 % CI: 0.02-0.32; p = 0.0006). No significant difference was found in hospital length of stay between the two groups. Multivariate analysis did not show a significant relationship between hospital length of stay and gelatin torpedoes embolization technique. No embolic complication occurred in the gelatin group.

Conclusion

Gelatin torpedoes embolization technique after PRFA of lung neoplastic lesions resulted in significantly reduced chest tube placement rate in our patient population. No significant reduction in hospital length of stay was observed. No major complication occurred in the gelatin group.

Association between needle track bleeding and postoperative immediate pneumothorax in CT-guided percutaneous transthoracic lung biopsies: a cross-sectional study

The relationship between Needle Track Bleeding (NTB) and the occurrence of postoperative immediate pneumothorax remains unclear. In our cross-sectional study, we conducted a retrospective collected of data from 674 consecutive patients who underwent CT-guided percutaneous transthoracic lung biopsies between 2019 and 2022. A logistic regression model was employed to explore the association between NTB and postoperative immediate pneumothorax, and restricted cubic spline curves was used to investigate the link and its explicit curve shape. A sensitivity analysis was performed by transforming the continuous NTB into categorical variable and calculated an E-value. A total of 453 participants (47.90% male) were included in our analysis. The postoperative immediate pneumothorax rate was 41.05% (186/453). We found a negative correlation between NTB and postoperative immediate pneumothorax (OR = 0.91, 95%CI 0.88-0.95) after adjusting for confounding factors. This relationship was nonlinear, with a key inflection point at NTB of 8 mm. No significant link was noted for NTB > 8 mm (OR = 0.98, 95%CI 0.95-1.02), while a protective association was observed for NTB ≤ 8 mm (OR = 0.74, 95%CI 0.66-0.81). NTB showed a nonlinear, protective correlation with postoperative immediate pneumothorax. However, when NTB exceeded 8 mm, the protective association was not observed.

Case report: A rare complication after the implantation of a cardiac implantable electronic device: Contralateral pneumothorax with pneumopericardium and pneumomediastinum

Cardiac implantable electronic devices (CIED) including pacemakers (PM), implantable cardioverter defibrillators (ICD), and cardiac resynchronized therapy (CRT) have become the mainstay of therapy for many cardiac conditions, consequently drawing attention to the risks and benefits of these procedures. Although CIED implantation is usually a safe procedure, pneumothorax remains an important complication and may contribute to increased morbidity, mortality, length of stay, and hospital costs. On the other hand, pneumopericardium and pneumomediastinum are rare but potentially fatal complications. Accordingly, a high degree of awareness about these complications is important. Pneumothorax almost always occurs on the ipsilateral side of implantation. The development of contralateral pneumothorax is uncommon and may be undetected on an initial chest radiograph. Contralateral pneumothorax with concurrent pneumopericardium and pneumomediastinum is much rarer. We describe a rare case of concurrent right-sided pneumothorax with pneumopericardium and pneumomediastinum after left-sided pacemaker implantation and highlight the risk factors, management, and possible ways to prevent the complications.

Safety and efficacy of vacuum bottle plus catheter for drainage of iatrogenic pneumothorax

Background

Iatrogenic pneumothorax is common after thoracic procedures. For patients with pneumothorax larger than 15%, simple aspiration is suggested. Although vacuum bottle plus non-tunneled catheter drainage has been performed in many institutions, its safety and efficacy remain to be assessed.

Methods

Through this prospective cohort study (NCT03724721), we evaluated the safety and efficacy of vacuum bottle plus non-tunneled catheter drainage. Patients older than 20 years old who developed post-procedural pneumothorax were enrolled. A non-tunneled catheter was placed at the intersection of the midclavicular line and the second intercostal space. A 3-way stopcock, a drainage set, and a digital pressure gauge were connected. The stopcock was manipulated to connect the pleural space to the pressure gauge for measurement of end-expiration intrapleural pressure or to the vacuum bottle for air drainage. The rate of successful drainage, the end-expiration intrapleural pressure before, during, and after the procedure and the duration of hospitalization were recorded.

Results

From August 2018 to February 2020, 21 patients underwent vacuum bottle plus catheter drainage (intervention group) and 31 patients received conservative treatment (control group). The end-expiration intrapleural pressure of all patients remained less than − 20 cmH₂O during drainage. No procedure related complication was observed. Large pneumothorax (≥ 15%) was associated with higher risk of persistent air leak (Odds ratio 12, 95% CI 1.2–569.7). Vacuum bottle assisted air drainage yielded shorter event-free duration than that of conservative treatment (2 days vs 5 days [interquartile range 1–4 days vs 3–7 days], p < .05). Vacuum bottle assisted air drainage also help identifying patients with persistent pneumothorax and necessitate the subsequent management. The event-free duration of persistent air leak in the intervention group was also comparable with that of conservative treatment (5 days vs 5 days [interquartile range 5–8 days vs 3–7 days], p = .45).

Conclusions

Vacuum bottle plus catheter drainage of iatrogenic pneumothorax is a safe and efficient procedure. It may be considered as an alternative management of stable post-procedural pneumothorax with size larger than 15%.

Trial registration The study protocol was approved by the Research Ethics Committee of National Taiwan University Hospital (No. 201805105DINA) on 6th August, 2018. The first participant was enrolled on 23rd August, 2018 after Research Ethics Committee approval. This clinical trial complete registration at U.S. National Library of Medicine clinicaltrials.gov with identifier NCT03724721 and URL: https://clinicaltrials.gov/ct2/show/NCT03724721 on 30th October, 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02009-8.

A Rare Complication of Fine-Needle Aspiration of Neck Structures

Fine-needle aspiration (FNA) is a generally accepted tool for safe diagnostic evaluation in the workup of lesions and masses. Aside from the commonly discussed risks of infection and minor bleeding related to skin puncture, other more serious complications have been reported sparingly. We present two cases of pneumothorax from FNA of neck structures, which have been theorized but not previously reported to our knowledge. Discussion of cases of this complication rather than solely a theoretical understanding of it will aid in diagnosis and management of this complication.

Safety and Efficacy of Manual Aspiration Via Small Bore Chest Tube in Facilitating the Outpatient Management of Transbronchial Biopsy-related Iatrogenic Pneumothorax

BACKGROUND

Iatrogenic pneumothorax complicates transbronchial biopsies with a prevalence of 1% to 6%. Conventional treatment consists of inpatient management with chest tube drainage. While aspiration techniques have been investigated in the management of both primary spontaneous and transthoracic lung biopsy-induced pneumothorax, its role in the management of transbronchial biopsy-iatrogenic pneumothorax (TBBX-IP) is undefined. An appealing treatment alternative for TBBX-IP may exist in the placement of a small bore chest tube (SBCT) followed by a manual aspiration (MA) technique promoting earlier SBCT removal to facilitate outpatient management. To our knowledge, no study exists evaluating the efficacy of MA via a SBCT performed specifically for TBBX-IP.

PATIENTS AND METHODS

Prospective evaluation of the efficacy of a protocolized pathway incorporating MA through a SBCT for the outpatient management of TBBX-IP. Primary outcome was the clinicoradiographic resolution of TBBX-IP avoiding hospitalizations.

RESULTS

A total of 763 biopsies performed; 31 complicated by TBBX-IP, 18 qualified for intervention. Sixteen were outpatients, 2 inpatients. Thirteen (81.25%) of the 16 outpatients were successfully treated with MA via SBCT and did not require admission. Twelve (75%) of these 13 had SBCT removed, 1 patient was discharged with SBCT and removed in 24 hours. Of the 18 patients requiring intervention, 13 (72.2%) were successfully treated with MA via SBCT enabling removal of SBCT. No patient required reintervention.

CONCLUSION

MA via SBCT represents a safe and viable management approach of TBBX-IP promoting earlier SBCT removal and decreased hospitalizations. Our results challenge conventional management of TBBX-IP warranting further investigation.

[Pneumothorax Following Gastric Endoscopic Mucosal Resection]

An endoscopic mucosal resection (EMR) is used widely as an alternative treatment to a surgical resection for early gastric neoplastic lesions. Among the unusual complications of gastric EMR, perforation is usually manifested as a pneumoperitoneum. This paper reports a patient with a left-side pneumothorax without pneumoperitoneum as a complication of gastric EMR. The patient developed a left side pneumothorax after gastric EMR in the gastric fundus and recovered without further complications after conservative treatment, including endoscopic clipping.

Immediate pneumothorax after neurosurgical procedures

Objective

Pneumothorax after neurosurgical procedures is very rare and incompletely understood. This study was performed to explore the clinical characteristics and pathogenesis of pneumothorax after neurosurgery.

Methods

We retrospectively evaluated patients admitted from December 2016 to April 2019 for treatment of spontaneous intracranial hemorrhage. The inclusion criteria were neurosurgical procedures (open surgeries or endovascular intervention) performed under general anesthesia, no performance of central venous puncture during surgery, and occurrence of pneumothorax immediately after the neurosurgical procedure.

Results

Eight patients developed pneumothorax after neurosurgical procedures for spontaneous intracranial hemorrhage under general anesthesia. Of the eight patients, seven had aneurysmal subarachnoid hemorrhage and one had left temporal–parietal hemorrhage. The lung injury prediction score (LIPS) was 3, 4, 5, 6, and 9.5 in three, one, two, one, and one patient, respectively. During the operation, volume-controlled ventilation (tidal volume, 8–10 mL/kg) was selected for all patients.

Conclusions

Neurogenic pulmonary edema, inappropriate mechanical ventilation, and stimulation by endotracheal intubation might conjointly contribute to postoperative pneumothorax. To avoid this rare entity, mechanical ventilation with a low tidal volume or low pressure during general anesthesia should be adopted for patients with hemorrhagic cerebrovascular diseases involving the temporal lobe and a LIPS of >3.

Bilateral tension pneumothorax during endoscopic submucosal dissection under general anesthesia diagnosed by point-of-care ultrasound - A case report

BACKGROUND

Endoscopic submucosal dissection has become popular. However, this can cause serious complications. In this case, esophageal perforation caused bilateral tension pneumothorax.

CASE

A 60-year-old man with esophageal adenoma underwent endoscopic submucosal dissection under general anesthesia. The peak airway pressure was 25 cmH2O after induction but abruptly increased to 40 cmH2O after 30 min. Respiratory sounds were barely heard. The lack of lung sliding in either (right-dominant) lung on ultrasound. Within minutes, oxygen saturation and systolic blood pressure decreased to 52% and 70 mmHg. Emergent needle thoracostomy, followed by chest tube insertion, was performed on right chest and his vital signs stabilized. Upon transfer to intensive care unit, oxygen saturation and blood pressure decreased again; therefore, a left chest tube was inserted.

CONCLUSIONS

Pneumothorax due to esophageal perforation can lead to life-threatening tension pneumothorax. Anesthesiologists should be aware of the risks and emergency treatment. Ultrasound can be useful for immediate bedside patient-care decisions.

Adverse Events in Hypoglossal Nerve Stimulator Implantation: 5-Year Analysis of the FDA MAUDE Database

OBJECTIVE

Use of hypoglossal nerve stimulator implantation has dramatically improved the surgical treatment of multilevel airway collapse during obstructive sleep apnea (OSA). Understanding causes of adverse events and their impact on patients undergoing stimulator implantation will help improve patient preparation and surgical practices to avoid future complications.

STUDY DESIGN

This study is a retrospective review of the US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database, a publicly available voluntary reporting system.

SETTING

National patient event database.

METHODS

The MAUDE database was searched for reports associated with the terms "hypoglossal nerve stimulator" and "Inspire," being the only currently FDA-approved system for upper airway stimulation for OSA. All records were searched with the events limited in dates between May 2014 and September 2019.

RESULTS

A total of 132 patient reports were identified over the 5-year inclusion period, containing 134 adverse events. The reported adverse events resulted in 32 device revision procedures as well as 17 explantations. Device migration and infection were 2 of the most commonly reported adverse events. Complications not witnessed in previous large-scale clinical trials included pneumothorax, pleural effusion, and lead migration into the pleural space.

CONCLUSION

Previous data have demonstrated hypoglossal nerve stimulator implantation results in reliable OSA improvement. However, a number of technical difficulties and complications still exist during the perioperative period, which should be communicated to patients during the surgical consent process.

Iatrogenic emergency medicine procedure complications and associated trouble-shooting strategies

PURPOSE

The purpose of this paper is to provide a consolidated reference for the acute management of selected iatrogenic procedural injuries occurring in the emergency department (ED).

DESIGN/METHODOLOGY/APPROACH

A literature search was performed utilizing PubMed, Scopus, Web of Science and Google Scholar for studies through March of 2017 investigating search terms "iatrogenic procedure complications," "error management" and "procedure complications," in addition to the search terms reflecting case reports involving the eight below listed procedure complications.

FINDINGS

This may be particularly helpful to academic faculty who supervise physicians in training who present a higher risk to cause such injuries.

ORIGINALITY/VALUE

Emergent procedures performed in the ED present a higher risk for iatrogenic injury than in more controlled settings. Many physicians are taught error-avoidance rather than how to handle errors when learning procedures. There is currently very limited literature on the error management of iatrogenic procedure complications in the ED.

Factors predicting the need for tube thoracostomy in patients with iatrogenic pneumothorax associated with computed tomography-guided transthoracic needle biopsy

Objectives

Traumatic iatrogenic pneumothorax occurs most often after a transthoracic needle biopsy. Since this procedure has become a common outpatient intervention, emergency department admissions of post-biopsy pneumothorax patients have increased. The aim of this study was to determine the factors that predict the need for tube thoracostomy in patients with post-biopsy pneumothorax in the emergency department.

Methods

A retrospective cross-sectional study was conducted on 191 patients with post-biopsy pneumothorax who were admitted to the emergency department between 2010 and 2017. Patient characteristics, clinical findings at the emergency department presentation, and procedural and radiological features were reviewed. A multivariate logistic regression model was constructed using the variables from univariate comparisons to determine the need for tube thoracostomy in patients with iatrogenic pneumothorax, and the effect sizes were demonstrated with odds ratios.

Results

Tube thoracostomies were performed on 69 out of 191 patients (36.1%). A total of 122 patients (63.9%) were treated with supplemental oxygen therapy without any other intervention, and 126 patients (66.0%) were hospitalized. In the multivariate model, the variables predicting the need for a tube thoracostomy were decreased breath sounds, dyspnea, decreased systolic blood pressure, decreased oxygen saturation and increased pleura–lesion distance. A distance of 19.7 mm predicted the need with a sensitivity of 69.6% and a specificity of 62.3%.

Conclusion

Decreased breath sounds, dyspnea, decreased systolic blood pressure, decreased oxygen saturation, and increased pleura-lesion distance may predict the need for a tube thoracostomy in patients with post-biopsy pneumothorax.

Iatrogenic pneumothorax during hypoglossal nerve stimulator implantation

Hypoglossal nerve stimulation is a promising new treatment for patients with obstructive sleep apnea. In the initial Stimulation Therapy for Apnea Reduction Trial, the overall rate of serious adverse events was <2% and no cases of pneumothorax were reported. We present the case of an iatrogenic pneumothorax during placement of the chest sensor lead between the intercostal muscles. Following clinical and radiological evaluation, surgery was continued and the patient was treated expectantly. In the following review, we discuss pathophysiology, diagnosis, and expected outcomes. Surgeons placing hypoglossal nerve stimulators should be aware of complications and prepared to manage a pneumothorax.

Depiction of pneumothoraces in a large animal model using x-ray dark-field radiography

The aim of this study was to assess the diagnostic value of x-ray dark-field radiography to detect pneumothoraces in a pig model. Eight pigs were imaged with an experimental grating-based large-animal dark-field scanner before and after induction of a unilateral pneumothorax. Image contrast-to-noise ratios between lung tissue and the air-filled pleural cavity were quantified for transmission and dark-field radiograms. The projected area in the object plane of the inflated lung was measured in dark-field images to quantify the collapse of lung parenchyma due to a pneumothorax. Means and standard deviations for lung sizes and signal intensities from dark-field and transmission images were tested for statistical significance using Student's two-tailed t-test for paired samples. The contrast-to-noise ratio between the air-filled pleural space of lateral pneumothoraces and lung tissue was significantly higher in the dark-field (3.65 ± 0.9) than in the transmission images (1.13 ± 1.1; p = 0.002). In case of dorsally located pneumothoraces, a significant decrease (-20.5%; p > 0.0001) in the projected area of inflated lung parenchyma was found after a pneumothorax was induced. Therefore, the detection of pneumothoraces in x-ray dark-field radiography was facilitated compared to transmission imaging in a large animal model.

Pneumothorax with prolonged chest tube requirement after CT-guided percutaneous lung biopsy: incidence and risk factors

PURPOSE

To evaluate the incidence and risk factors of pneumothoraces requiring prolonged maintenance of a chest tube following CT-guided percutaneous lung biopsy in a retrospective, single-centre case series.

MATERIALS AND METHODS

All patients undergoing CT-guided percutaneous lung biopsies between June 2012 and May 2014 who required chest tube insertion for symptomatic or enlarging pneumothoraces were identified. Based on chest tube dwell time, patients were divided into two groups: short term (0-2 days) or prolonged (3 or more days). The following risk factors were stratified between groups: patient demographics, target lesion characteristics, and procedural/periprocedural technique and outcomes.

RESULTS

A total of 2337 patients underwent lung biopsy; 543 developed pneumothorax (23.2 %), 187 required chest tube placement (8.0 %), and 55 required a chest tube for 3 days or more (2.9 % of all biopsies, 29.9 % of all chest tubes). The median chest tube dwell time for short-term and prolonged groups was 1.0 days and 4.7 days, respectively. The transfissural needle path predicted prolonged chest tube requirement (OR: 2.5; p = 0.023). Other factors were not significantly different between groups.

CONCLUSION

Of patients undergoing CT-guided lung biopsy, 2.9 % required a chest tube for 3 or more days. Transfissural needle path during biopsy was a risk factor for prolonged chest tube requirement.

KEY POINTS

• CT-guided percutaneous lung biopsy (CPLB) is an important method for diagnosing lung lesions • A total of 2.9 % of patients require a chest tube for ≥3 days following CPLB • Transfissural needle path is a risk factor for prolonged chest tube time.

Cardiac Implantable Electronic Device Implantation

Implantation of cardiac implantable electronic devices (CIEDs), including pacemakers, implantable cardioverter-defibrillators, and biventricular pacemakers/cardioverter-defibrillators, is becoming increasingly common with new implants now exceeding 1.5 million per year globally. As a result, health care providers in all disciplines are caring for an increasing number of patients with CIEDs. Although the risk of complications associated with implantation of CIEDs is relatively low, the sequela can be catastrophic. Management requires an understanding of an individual patient’s indication for CIED implant, the steps of implant procedures, device function, and natural history of each complication.