American Journal of Emergency Medicine 33 (2015) 970–982
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence Some tricks in iatrogenic pneumothorax☆
We read the article of Vinson et al [1] titled “Pneumothorax is a rare complication of thoracic central venous catheterization in community EDs.” We thank the authors about their well-designed study. Iatrogenic pneumothorax that occurred during central vein catheterization is generally related to the experience of the practitioner. When it becomes a routine for the practitioner, the number of iatrogenic pneumothorax decreases. However, we think that, in a teaching hospital, the incidence of this complication cannot be decreased because of the continuity of the education. Insertion of a needle to the lung does not always cause pneumothorax. It is declared that pneumothorax incidence after transthoracic needle biopsy is approximately 20% in general [2]. The occurrence of emphysema and/or bullous formation of the lung, the diameter of the needle, the extent of the needle passing the pleura, and the pleural adhesions determine the occurrence of pneumothorax in all kinds of interventional procedures to the lung including central venous catheterization. During the awake procedures of central venous catheterization, some incompatible patients may mimic symptoms of pneumothorax such as pain and shortness of breath. If the patient is stable and physical examination does not clearly reveal a pneumothorax, we should not perform an evacuation procedure, which may be unnecessary, before performing a radiological study. In some centers, central venous catheterization is performed with the help of an ultrasound, as mentioned in the text. Ultrasound can also be used for detection of pneumothorax [3]. We think that, with the help of ultrasound, overlooked occult pneumothorax cases can be detected. Radiological studies are performed after the catheterization procedure to verify the position of the catheter and to determine any complication. This approach is suitable for unilateral attempts. However, if an attempt from the contralateral side is needed, we recommend radiological studies “before” a contralateral attempt in order not to struggle with the complication of bilateral pneumothorax. We sometimes face bilateral pneumothorax after central vein catheterizations that require emergency evacuation. Sezai Çubuka, MD Gata Medical Faculty, Department of Thoracic Surgery, Ankara, Turkey Corresponding author. Department of Thoracic Surgery Gata Medical Faculty, Ankara, Turkey Tel.: +905424868489; fax: +903123533702 E-mail address: [email protected] Orhan Yücel Gata Haydarpasa Teaching Hospital, Department of Thoracic Surgery, Istanbul, Turkey E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.02.014 ☆ Conflict of interest: None declared. 0735-6757/© 2015 Elsevier Inc. All rights reserved.
References [1] Vinson DR, Ballard DW, Hance LG, Stevenson MD, Clague VA, Rauchwerger AS, et al. Pneumothorax is a rare complication of thoracic central venous catheterization in community EDs. Am J Emerg Med 2015;33(1):60–6. [2] Boskovic T, Stanic J, Pena-Karan S, Zarogoulidis P, Drevelegas K, Katsikogiannis N, et al. Pneumothorax after transthoracic needle biopsy of lung lesions under CT guidance. J Thorac Dis 2014;6(Suppl. 1):S99–S107. [3] Kumar S, Agarwal R, Aggarwal AN, Gupta D, Jindal SK. Role of ultrasonography in the diagnosis and management of pneumothorax following transbronchial lung biopsy. J Bronchol Interv Pulmonol 2015;22(1):14–9.
The indications for screening chest radiography after failed thoracic central venous catheterization
To the Editor,
We thank Drs. Sezai and Yücel for their interest in our central venous catheterization research and welcome this opportunity to respond to their recommendation to routinely obtain a postprocedural chest radiograph after an unsuccessful thoracic central venous catheterization before attempting a contralateral thoracic central line. Although the intention is very well placed—avoiding iatrogenic bilateral pneumothoraces—we are not sure the incidence of this rare complication is sufficiently high to warrant a policy of universal postattempt radiography. In our series of 1249 cases, we found a very low rate of immediate pneumothorax in patients receiving catheterization exclusively of the internal jugular (IJ) vein (0.1%) as well as in patients who did not receive positive-pressure ventilation throughout their emergency department stay (0.1%) [1]. If a nonventilated patient underwent an unsuccessful right IJ vein catheterization, followed by an attempt at catheterizing the left IJ vein, the odds of developing bilateral pneumothoraces are extremely low. Assuming even a substantially inflated incidence of 0.5% at each side, the risk of bilateral pneumothorax would be approximately 1 in 40 000. Insisting on a postprocedural radiograph in every case is not without its downsides. If a patient urgently needed central venous access for time-sensitive treatment, as in a critically ill septic patient without peripheral access, the further delay in care attending additional imaging may be harmful. Moreover, using the above conservative risk estimates and an estimated cost for a portable chest radiograph of US $100, at least US $4 million would be spent to prevent 1 case of bilateral pneumothoraces. However, not all thoracic central line cases carry the same risk of collapsing a lung. The odds of pneumothorax are higher in ventilated patients as well as those undergoing catheterization of the subclavian vein. In these slightly higher risk cases, if not pressed for emergent venous access, it might be prudent to exclude pneumothorax on the
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence Some tricks in iatrogenic pneumothorax☆
We read the article of Vinson et al [1] titled “Pneumothorax is a rare complication of thoracic central venous catheterization in community EDs.” We thank the authors about their well-designed study. Iatrogenic pneumothorax that occurred during central vein catheterization is generally related to the experience of the practitioner. When it becomes a routine for the practitioner, the number of iatrogenic pneumothorax decreases. However, we think that, in a teaching hospital, the incidence of this complication cannot be decreased because of the continuity of the education. Insertion of a needle to the lung does not always cause pneumothorax. It is declared that pneumothorax incidence after transthoracic needle biopsy is approximately 20% in general [2]. The occurrence of emphysema and/or bullous formation of the lung, the diameter of the needle, the extent of the needle passing the pleura, and the pleural adhesions determine the occurrence of pneumothorax in all kinds of interventional procedures to the lung including central venous catheterization. During the awake procedures of central venous catheterization, some incompatible patients may mimic symptoms of pneumothorax such as pain and shortness of breath. If the patient is stable and physical examination does not clearly reveal a pneumothorax, we should not perform an evacuation procedure, which may be unnecessary, before performing a radiological study. In some centers, central venous catheterization is performed with the help of an ultrasound, as mentioned in the text. Ultrasound can also be used for detection of pneumothorax [3]. We think that, with the help of ultrasound, overlooked occult pneumothorax cases can be detected. Radiological studies are performed after the catheterization procedure to verify the position of the catheter and to determine any complication. This approach is suitable for unilateral attempts. However, if an attempt from the contralateral side is needed, we recommend radiological studies “before” a contralateral attempt in order not to struggle with the complication of bilateral pneumothorax. We sometimes face bilateral pneumothorax after central vein catheterizations that require emergency evacuation. Sezai Çubuka, MD Gata Medical Faculty, Department of Thoracic Surgery, Ankara, Turkey Corresponding author. Department of Thoracic Surgery Gata Medical Faculty, Ankara, Turkey Tel.: +905424868489; fax: +903123533702 E-mail address: [email protected] Orhan Yücel Gata Haydarpasa Teaching Hospital, Department of Thoracic Surgery, Istanbul, Turkey E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.02.014 ☆ Conflict of interest: None declared. 0735-6757/© 2015 Elsevier Inc. All rights reserved.
References [1] Vinson DR, Ballard DW, Hance LG, Stevenson MD, Clague VA, Rauchwerger AS, et al. Pneumothorax is a rare complication of thoracic central venous catheterization in community EDs. Am J Emerg Med 2015;33(1):60–6. [2] Boskovic T, Stanic J, Pena-Karan S, Zarogoulidis P, Drevelegas K, Katsikogiannis N, et al. Pneumothorax after transthoracic needle biopsy of lung lesions under CT guidance. J Thorac Dis 2014;6(Suppl. 1):S99–S107. [3] Kumar S, Agarwal R, Aggarwal AN, Gupta D, Jindal SK. Role of ultrasonography in the diagnosis and management of pneumothorax following transbronchial lung biopsy. J Bronchol Interv Pulmonol 2015;22(1):14–9.
The indications for screening chest radiography after failed thoracic central venous catheterization
To the Editor,
We thank Drs. Sezai and Yücel for their interest in our central venous catheterization research and welcome this opportunity to respond to their recommendation to routinely obtain a postprocedural chest radiograph after an unsuccessful thoracic central venous catheterization before attempting a contralateral thoracic central line. Although the intention is very well placed—avoiding iatrogenic bilateral pneumothoraces—we are not sure the incidence of this rare complication is sufficiently high to warrant a policy of universal postattempt radiography. In our series of 1249 cases, we found a very low rate of immediate pneumothorax in patients receiving catheterization exclusively of the internal jugular (IJ) vein (0.1%) as well as in patients who did not receive positive-pressure ventilation throughout their emergency department stay (0.1%) [1]. If a nonventilated patient underwent an unsuccessful right IJ vein catheterization, followed by an attempt at catheterizing the left IJ vein, the odds of developing bilateral pneumothoraces are extremely low. Assuming even a substantially inflated incidence of 0.5% at each side, the risk of bilateral pneumothorax would be approximately 1 in 40 000. Insisting on a postprocedural radiograph in every case is not without its downsides. If a patient urgently needed central venous access for time-sensitive treatment, as in a critically ill septic patient without peripheral access, the further delay in care attending additional imaging may be harmful. Moreover, using the above conservative risk estimates and an estimated cost for a portable chest radiograph of US $100, at least US $4 million would be spent to prevent 1 case of bilateral pneumothoraces. However, not all thoracic central line cases carry the same risk of collapsing a lung. The odds of pneumothorax are higher in ventilated patients as well as those undergoing catheterization of the subclavian vein. In these slightly higher risk cases, if not pressed for emergent venous access, it might be prudent to exclude pneumothorax on the
