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Pneumothorax: Introduction

Overview and Implications

A pneumothorax is present when there is air in the pleural space. Pneumothoraces are classified as spontaneous, which develop without preceding trauma or other obvious cause, and traumatic, which develop as a result of direct or indirect trauma to the chest. Traumatic pneumothoraces can be either iatrogenic or non-iatrogenic (Light & Lee, 2016). An iatrogenic pneumothorax (IP) is a known complication of invasive procedures such as pulmonary needle biopsy (transthoracic and transbronchial), placement of a central venous line, or positive pressure ventilation. However, this condition can arise from many other procedures involving the thorax and abdomen. Subclavian insertion of a central venous line (CVL) is the most common procedure associated with an iatrogenic pneumothorax (Ojeda Rodriguez & Hipskind, 2021) and is the focus of this indicator.

In the Measuring Patient Harm in Canadian Hospitals, the Canadian Institute for Health Information (CIHI) reported that of the 181,596 harmful events identified in the Data Quality Study of the 2015–2016 Discharge Abstract Database; 1.1 per cent were due to pneumothorax from a medical or surgical procedure (Chan et al., 2016) and 2,100 pneumothoraces were reported in 2019-2020 (CIHI, 2020). AHRQ reports the 2020 rate of IP per 1,000 at 0.19 in the United States (AHRQ, 2020).

A tension pneumothorax is present when the air accumulates in the pleural space to a point where the increasing pressure impedes normal cardiovascular function. [It] can occur with any of the types of pneumothorax but occur more commonly in patients receiving positive pressure ventilation or CPR [and] can lead - often quite suddenly - to life-threatening hypotension and shock (Light & Lee, 2016).

Iatrogenic pneumothoraces is a potentially life-threatening complication seen in three per cent of ICU patients (Chen et al., 2002; Anzueto et al., 2004; de Lassence et al., 2006). It has been associated with an increase in ICU and hospital length of stay, and resource utilization (Amato et al., 1998; Anzueto et al., 2004; de Lassence et al., 2006; Zhan et al., 2006), as well as an increase in the risk of death (Gattinoni et al., 1994, Schnapp et al., 1995, Esteban et al., 2002).

IP is largely preventable (de Lassence et al., 2006). In the ICU setting, the currently low three per cent incidence of IP was around eight per cent in the 1980s (de Lassence et al., 2006). This decrease is believed to be due to improved equipment, techniques, and safer practices both for mechanical ventilation and procedure- related pneumothorax (Çelik et al., 2009).

The incidence of procedure-related pneumothorax has also been reduced by improved equipment (e.g., ultrasound), education, and training; these improvements have equally been noted in the non-ICU and pediatric settings (Duncan et al., 2009; Gordon et al., 2010; Havelock et al., 2010; Lenchus et al., 2010; Cavanna et al., 2010; Troianos et al., 2012).

Procedures associated with iatrogenic pneumothorax§

Any intervention in proximity to the abdomen, especially the thorax, can cause an iatrogenic pneumothorax. This is especially true when placing a subclavian central venous catheter without the use of ultrasound (i.e., "blindly") using landmarks. In landmark-based subclavian central venous catheter placement, per Kilbourne et al., six common technical errors include inadequate landmark identification, improper insertion position, insertion of the needle through periosteum, taking too shallow a trajectory with the needle, aiming the needle to cephalad, and failure to keep the needle in place for wire passage. Landmark technique also depends on the ability and experience of the medical professional performing the procedure, making iatrogenic pneumothorax more likely in a tertiary teaching hospital (Ojeda Rodriguez & Hipskind, 2021).

Other procedures associated with IP:

  • Dry needling (Health Quality Council of Alberta, 2014).
  • Airway-related: endotracheal tube insertion (intubation) or misplacement (neonates), inadequate clearance of trapped secretions, positive airway pressure devices (Carron et al., 2007; Chebel et al., 2010; Hegde & Prodhan, 2013; Milési et al., 2014).
  • Surgical: tracheostomy, thoracotomy, mediastinoscopy, cardiac surgery, insertion/revision/replacement/removal of cardiac pacemaker or cardioverter/defibrillator, breast augmentation, rarely: abdominal cavity operations.
  • Cardiopulmonary resuscitation (CPR).

Patient Risk Factors

Patient factors that increase the risk of pneumothorax in the setting of an intervention include:

  • Age.
  • Low body weight.*
  • Poor healing ability (chronic corticosteroid use, malnutrition).
  • Severity of acute illness.*
  • Acute or chronic pulmonary¹ or pleural¥ disease.
  • Agitation.
  • AIDS.*

Goal

To prevent iatrogenic pneumothorax in hospitalized adult patients by implementing best practices for risk reduction.

Table of Contents

§ Anzueto et al., 2004; de Lassence et al., 2006; Zhan et al., 2006; Çelik et al., 2009; Loiselle et al., 2013; Light & Lee, 2016, Ojeda Rodriguez & Hipskind, 2021

* Noted for ICU patients of all ages (de Lassence et al., 2006).

¹ Bronchopulmonary dysplasia, acute bronchiolitis, COPD, Adult or neonatal Respiratory Distress Syndrome, cardiogenic pulmonary edema, pneumonia, primary lung cancer (Anzueto et al., 2004).

¥ Malignant and parapneumonic pleural effusion, empyema (Nyman et al., 2008).