Evaluation of conventional chest tube therapy for iatrogenic pneumothorax

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.

Managing iatrogenic pneumothorax and chest tubes

Iatrogenic pneumothorax has become an increasingly recognized complication of routine outpatient procedures, such as transthoracic needle biopsies of the lung and transbronchial lung biopsies. Patients with clinically significant pneumothorax are typically managed with evacuation via a percutaneously placed catheter or chest tube. Tube thoracotomy and chest tube management have traditionally been performed by cardiothoracic surgeons; however, with the increasing number of interventional radiologists and interventional pulmonologists, more chest tubes are being placed by specialists who do not admit and manage patients in the hospital setting. The responsibility for the admission of these patients to the hospital service has fallen to the internist. Hospitalists caring for such patients are often expected to manage the chest tube. General internal medicine training and the existing medical literature provide few guidelines to assist with this issue. We present a discussion of the current published literature and our management algorithms for hospitalists caring for patients admitted with iatrogenic pneumothorax.

Accidental Iatrogenic Pneumothorax in Hospitalized Patients

OBJECTIVE

Iatrogenic pneumothorax (IP) is an inherent risk to patients who undergo procedures that involve the intentional puncturing of the lung. IP also could occur accidentally to patients who do not undergo such procedures; such accidental IP (AIP) is suggestive of lapses in safe care. This study assessed the risk for AIP in patients hospitalized with specific diagnoses who underwent specific procedures.

RESEARCH DESIGN

We analyzed 7.5 million discharge abstracts from 994 short-term acute care hospitals across 28 states in 2000 in the Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project Nationwide Inpatient Sample. AHRQ Patient Safety Indicators (PSIs) were used to identify AIP. AIP incidences and associated diagnoses and procedures were explored.

RESULTS

Patients who were admitted for pleurisy, cancer of the kidney and renal pelvis, or conduction disorders and complications of cardiac devices had the highest rates of developing AIP during hospitalization, with AIP rates at 2.24%, 1.14%, and 0.83% respectively. The procedure-specific rates for AIP varied from 2.68% for patients who underwent thoracentesis to 1.30% for those who underwent nephrectomy, to 0.06% for those who underwent gastrostomy. Thoracentesis appeared to be a high-risk procedure for patients who were admitted for secondary malignancies, pleurisy, or pneumonia, with AIP rates at 3.76%, 3.13%, and 2.28%, respectively.

CONCLUSIONS

Although AIP is most common after thoracentesis, it is a substantial threat to patients undergoing a wide range of procedures.

Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study

Although there is no agreement on the optimal treatment of patients presenting with a first episode of primary spontaneous pneumothorax, the majority of physicians prefer chest tube drainage for air evacuation. Manual aspiration of air has been proposed by some, but lack of sound comparative data and safety data has limited its use. In this first randomized, prospective, multicenter pilot study, 60 patients with a first episode of primary spontaneous pneumothorax were randomly allocated to manual aspiration (n = 27) or chest tube drainage (n = 33). Immediate success was obtained in 16 out of 27 (59.3%) in the manual aspiration group, and in 21 out of 33 (63.6%) in the chest tube drainage group (p = 0.9). One-week success rates were 25 out of 27 (93%) in the intention-to-treat manual aspiration group and 28 out of 33 (85%) in the chest tube drainage group (p = 0.4). Fourteen of 27 manual aspiration patients (52%) were hospitalized, versus 100% of the chest tube drainage patients (p < 0.0001). Recurrence rates with at least 1-year follow-up were 7 out of 26 (26%) in the manual aspiration group, and 9 out of 33 (27.3%) in the chest tube drainage group (p = 0.9). There were no complications associated with manual aspiration. Although statistical power is insufficient to formally confirm therapeutic equality, this pilot study suggests that in first episodes of primary spontaneous pneumothorax, manual aspiration seems equally effective as chest tube drainage and is safe, well tolerated, and feasible as an outpatient procedure in the majority of patients.

A regional survey of chest drains: evidence-based practice?

Although the use of chest drains is common in medicine, there appear to be wide variations in practice. A survey was therefore conducted to establish the current status of chest drain management in the Northwest region. A questionnaire targeted consultants practising in the specialties of chest medicine, general surgery, accident & emergency and cardiothoracic surgery. The questionnaire consisted of five sections encompassing aspects of the insertion, day-to-day care and removal of chest drains. With an overall response rate of 75.3% (110/146), important variations in every major aspect of the practice of chest drains were found between the specialties and to a large extent within each specialty. We have made a number of recommendations which aim to encourage good practice and reduce unnecessary complications, including the adoption of standardised protocols for inserting and managing chest drains.

Use of endoscopic trocar-cannula for chest drain insertion in trauma patients and others

BACKGROUND

The insertion of a chest drain into the pleural space is a common procedure used for treatment in various intrathoracic abnormalities. Recently, a new technique for chest-tube insertion for pleural cavity drainage, using the disposable endoscopic trocar-cannula, was described for the treatment of some pathologic conditions.

METHODS

In a prospective study, we used this technique in the treatment of patients with chest trauma, spontaneous and iatrogenic pneumothorax, and various kinds of pleural effusion.

RESULTS

One hundred twelve patients were treated by using the endoscopic trocar-cannula for tube insertion into the pleural cavity. Among them, 39 patients were treated after blunt and penetrating chest trauma. Most cannulae were of 10 to 11 mm in diameter, which enabled the insertion of large-bore drain tubes. In five trauma patients, chest-tube insertion was done successfully without antecedent chest x-ray films. The complication rate was 0.89% for intrapulmonary positioning of a chest tube in a patient who had previous ipsilateral thoracic surgery.

CONCLUSION

The use of endoscopic trocar-cannulae for chest-tube insertion is a safe, simple, and effective technique for management of trauma and other diverse intrathoracic abnormalities. Its use outside the hospital should be further studied.

Use of pleural catheter for the management of simple pneumothorax

STUDY OBJECTIVE

We assessed the use of a pleural catheter (Thoracic Vent) to determine its effectiveness in treating simple pneumothorax (PTX) and in preventing recurrent PTX.

DESIGN

A retrospective review was conducted of 84 patients treated with a pleural catheter for iatrogenic (52) and spontaneous (11 primary, 21 secondary) PTX between 1989 and 1994.

PATIENTS

There were 45 men and 39 women with a mean age of 50.4 years (range, 18 to 85 years).

RESULTS

Mean time to lung reexpansion was 0.5 +/- 0.1 days. Forty-five (57%) patients manifested an air leak after catheter placement for 2.0 +/- 0.2 days. The duration of time to catheter removal was 3.3 +/- 0.2 days. Seventy-one (85%) patients had resolution of PTX with this therapy alone. Thirteen patients (15%) failed to resolve their PTXs and required subsequent tube thoracostomy alone (6) or surgical therapy (7). Four of 11 patients who required tube thoracostomy also failed to respond to this therapy. Treatment failure was more common among patients with spontaneous PTX than with iatrogenic PTX (34% vs 4%; p < 0.005). During a mean follow-up of 3.0 +/- 0.2 years, 6 (7%) patients suffered recurrent PTX an average of 23 days after initial therapy.

CONCLUSION

This pleural catheter is effective in the management of simple iatrogenic and spontaneous PTX.