Iatrogenic pneumothorax

Background

Causes

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

Differential Diagnosis

Pneumothorax Types

The pleural cavity is normally a potential space, in which air collects in a pneumothorax.

• Tension pneumothorax
• Spontaneous pneumothorax
  • Catamenial pneumothorax
• Traumatic pneumothorax
  • Iatrogenic pneumothorax

Diagnosis

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

• CXR
  • Displaced visceral pleural line without lung markings between pleural line and chest wall
  • Upright is best
    • Expiratory films DO NOT improve accuracy
    • Lateral decubitus films with suspected side up do increase sensitivity. Good approach in pediatrics to avoid CT
  • Supine CXR = deep sulcus sign
• CT Chest
  • Very sensitive and specific

Management

Supplemental oxygen (non-rebreather mask) initially for all

Unstable

• Needle decompresion followed by chest tube insertion

Stable

Not on Positive Pressure

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

On Positive Pressure Ventilation

• Needle decompresion followed by chest tube insertion

Adult Chest Tube Sizes

Chest Tube Size	Type of Patient	Underlying Causes
Small (8-14 Fr)	Most spontaneous pneumothorax (primary and secondary) Most iatrogenic pneumothorax	Alveolar-pleural fistulae (small air leak) Iatrogenic air
Medium (20-28 Fr)	Traumatic pneumothorax Traumatic hemothorax ("any acute hemothorax visible on chest radiograph") Pneumothorax on mechanical ventilation Non-traumatic tension pneumothorax Malignant effusion	Trauma/bleeding (hemothorax/hemopneumothorax) Bronchial-pleural fistulae (large air leak) Malignant fluid
Large (36-40 Fr)	Empyema	Thick pus

See Also

• Pneumothorax (main)