A pneumothorax (a term for collapsed lung) occurs when air leaks into the space between a patient's lung and chest wall, creating pressure against the lung. Depending on how much air has leaked in, the patient's lung may only be partially collapsed or it may collapse completely. The greater the pneumothorax, the more it will interfere with normal breathing and may even become life-threatening. The occurrence of a pneumothorax during hospitalization is likely to prolong hospital stay.
A Case of Iatrogenic Pneumothorax
Ms. I. Ava Numeau, a 72-year old woman, underwent insertion of a central venous catheter via a subclavian approach in preparation for a right hemicolectomy. Now, she's restless and complains of shortness of breath and pleuritic chest pain. You take her vital signs: blood pressure 175/95, heart rate 115, respirations 28 and room air SpO2 89 per cent. On examination, she appears in mild-moderate respiratory distress. Over the left hemi thorax there is hyper-resonance to percussion and diminished air entry to auscultation.
Ms. Numeau was admitted the previous day for resection of a cecal adenocarcinoma, which caused significant weight loss from symptomatic recurrent intermittent incomplete bowel obstruction. Her past medical history includes hypertension controlled with medication and rheumatoid arthritis for which she is on chronic corticosteroids. Her preadmission examination was unremarkable except for integumentary signs of chronic steroid use, early muscle wasting, and mild abdominal distension. After unsuccessful attempts at obtaining peripheral venous access and inability to insert an internal jugular venous catheter due to limited cervical spine and shoulder mobility, the physician inserted a central venous catheter via the left subclavian vein.
Ms. Numeau's history reveals several risk factors for pneumothorax and the bedside assessment is suggestive of an iatrogenic pneumothorax.
The event could have been prevented by the use of bedside ultrasound-guided insertion of the internal jugular vein, which may have required only minimal neck/shoulder positioning. In addition, a Trendelenburg positioning would have increased the size of the great thoracic veins thus facilitating central venous insertion/cannulation. Finally, a peripherally-inserted central catheter (PICC) could also have been entertained, depending on the skillset of the medical provider.
Ms. Numeau's nurse provided her with 100 per cent oxygen while monitoring her vital signs. A stat portable chest X-ray was done, confirming the diagnosis and the rapid response team prepared to insert a chest tube with a 14-gauge I.V. catheter at the bedside if the patient developed signs of tension pneumothorax. The patient received appropriate procedural sedation and analgesia. Within minutes of chest tube insertion, her vital signs normalized and her chest pain and dyspnea resolved. Repeat chest X-ray confirmed proper positioning of the chest tube and resolution of the pneumothorax.