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On alert for iatrogenic pneumothorax

Day, Michael W. MSN, RN, CCRN

doi: 10.1097/01.NURSE.0000396448.19994.21
Department: PATIENT SAFETY
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Michael W. Day is a trauma nurse coordinator at Providence Sacred Heart Medical Center and Children's Hospital in Spokane, Wash., and a member of the Nursing2011 editorial board.

MR. S HAS JUST returned to your unit following a transbronchial biopsy (TBB) of a left upper lobe (LUL) lung mass. Your initial assessment findings include equal, clear breath sounds and a SpO2 of 94% on room air. Other than the LUL mass, his postprocedure supine chest X-ray is normal.

A half hour later, you find him in respiratory distress with a SpO2 of 82% and markedly diminished breath sounds on the left. He states he started having left-sided chest pain and trouble breathing about 15 minutes earlier but thought it would get better on its own. You suspect that Mr. S may have an iatrogenic pneumothorax and immediately activate the rapid response team.

An iatrogenic condition is induced by a medical treatment or procedure. This article discusses risk factors associated with iatrogenic pneumothorax, as well as patient assessment and management. But first, consider the causes.

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Taking on air

An iatrogenic pneumothorax occurs when air enters the pleural space during a medical treatment or procedure, such as Mr. S's TBB. (See What can cause an iatrogenic pneumothorax?) If a small amount of air enters the pleural space, the patient may be asymptomatic, but larger amounts of air can cause a partial or complete lung collapse. The result is decreased vital capacity and Sao2. Potential complications include tension pneumothorax, the accumulation of air in the pleural space causing mediastinal shift and circulatory collapse. This is a medical emergency requiring immediate intervention.

A patient who's on positive pressure ventilation or who's hemodynamically unstable must be treated immediately with a needle chest decompression followed by chest tube insertion. In severe cases, even a short delay to obtain an X-ray or to place chest tube can be fatal.

The good news is that the incidence of iatrogenic pneumothorax has decreased from more than 20% in the 1990s to approximately 3%.1

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What to watch for

Be vigilant in monitoring your patient for iatrogenic pneumothorax following any procedure known to increase the risk. Any time a patient demonstrates classic signs and symptoms associated with pneumothorax within several hours of a risky procedure, presume the patient has a pneumothorax until proven otherwise. (See Stay alert for problems.)

In patients receiving mechanical ventilation, assess for a sudden increase in peak airway pressures in addition to classic signs and symptoms. If the patient is being ventilated with a manual self-inflating resuscitation bag-valve device and increasing pressure is required to deliver the breaths, be alert to the possibility of a pneumothorax.

Should the pneumothorax progress to a tension pneumothorax, additional assessment findings may include jugular vein distension, profound tachycardia, profound tachypnea, absent breath sounds on the affected side, hypotension, cyanosis, significantly increased airway pressures in a mechanically ventilated patient, a deviated trachea (late sign), or pulseless electrical activity.?2 Because a suspected tension pneumothorax must be treated without delay, diagnosis is made on the basis of clinical findings, not an X-ray.

If time allows, a diagnosis is usually quickly established with an erect chest X-ray, which shows the absence of pulmonary vessel markings on the periphery of the lung. A chest X-ray taken immediately after a procedure may be negative for pneumothorax simply because it hasn't developed yet (delayed pneumothorax).

If the distance from the apex of the lung to the top margin of the visceral pleura is less than 3 cm, the pneumothorax is considered small; if it's more than 3 cm, it's considered large.3 A supine chest X-ray may not clearly show the absence of pulmonary markings, but a pneumothorax may be indicated by a very dark, deep costophrenic angle, known as the deep sulcus sign. The costophrenic angle is abnormally deepened when air collects in the lateral aspects of the chest.3

Additional diagnostic studies (depending on the patient's hemodynamic stability) may include computed tomography, which can identify small or occult pneumothoraces; ultrasonography, which may be done at the bedside; and contrast-enhanced esophagoscopy for a patient with suspected esophageal perforations.3

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How to manage patient care

When an iatrogenic pneumothorax is suspected, initial nursing care includes assessing and supporting the ABCs, and monitoring vital signs and SpO2. Administer high-flow oxygen to treat hypoxemia and help reabsorb pleural air, and make sure that the patient has a patent venous access. In addition, follow these guidelines.3

  • If the patient is hemodynamically stable and asymptomatic and the pneumothorax is small, simple observation may be appropriate.
  • If the patient is hemodynamically stable and symptomatic and has a small pneumothorax, the healthcare provider may prescribe observation for several hours or perform a needle aspiration of the pleural air.
  • If the pneumothorax is estimated to be too large to aspirate with a single syringe, the healthcare provider may insert a soft pigtail catheter and use a three-way stopcock or Heimlich valve.
  • If the pneumothorax persists, the catheter may be connected to a chest drainage unit (CDU).
  • If the patient is hemodynamically unstable, a needle chest decompression may be required while preparations are made for immediate chest tube insertion with a CDU set to the prescribed suction level.

A follow-up chest X-ray should be obtained to determine resolution, progression, or recurrence of pneumothorax.

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Focus on prevention

Many procedures, such as cardiothoracic surgery, inherently result in unavoidable pneumothorax, requiring chest tube placement. Other procedures that shouldn't cause pneumothorax (such as central venous access device insertion, mechanical ventilation, and thoracentesis) sometimes can cause pneumothorax.

Because you may be on the front line helping to evaluate and resolve this complication, being familiar with each procedure and ensuring that all team members adhere to the correct process can have a positive impact on patient outcomes. For example, practitioners should abandon efforts to insert a central venous catheter after two unsuccessful attempts.1

Evidence-based practice has demonstrated the effectiveness of team communication, "time-outs," and full barrier precautions for invasive procedures.4,5 In addition, advances in ventilator management have resulted in lower tidal volumes and pressure limits, decreasing the incidence of iatrogenic pneumothorax in mechanically ventilated patients.1

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Returning to Mr. S

A stat upright chest X-ray reveals a large left pneumothorax, requiring chest tube placement. A subsequent chest X-ray demonstrates proper chest tube placement and reexpansion of the left lung. The chest tube is removed the next day, and Mr. S returns home the day after that—but not before stopping to thank you for helping to save his life.

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What can cause an iatrogenic pneumothorax?3,6,7

  • transthoracic needle aspiration or biopsy
  • thoracentesis
  • tracheostomy
  • pleural biopsy
  • transbronchial lung biopsy
  • subclavian or jugular vein cannulation
  • mechanical ventilation
  • CPR
  • blind nasogastric or nasoduodenal feeding tube insertion
  • liver or kidney biopsy
  • computed tomography-guided radiofrequency tumor ablation
  • acupuncture
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Stay alert for problems6,7

Signs and symptoms of iatrogenic pneumothorax include:

  • ipsilateral chest pain that may radiate to neck, back, and shoulder
  • hemodynamic instability
  • tachycardia
  • tachypnea
  • dyspnea
  • hypoxemia
  • ipsilateral decreased or absent breath sounds
  • ipsilateral hyperresonance
  • cough
  • increased airway pressures in a mechanically ventilated patient.
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REFERENCES

1. de Lassence A, Timsit JF, Tafflet M, et al. Pneumothorax in the intensive care unit: incidence, risk factors, and outcome. Anesthesiology. 2006;104(1):5–13.
2. Emergency Nurses Association. Trauma Nurse Core Curriculum (TNCC). 7th ed. rev. Des Plains, Ill; 2007.
3. Chang AK, Mukherji P. Pneumothorax, iatrogenic, spontaneous and pneumomediastinum. 2010 .
4. Agency for Healthcare Research and Quality (AHQR). AHQR quality indicators: guide to patient safety indicators. 2007 .
5. Agency for Healthcare Research and Quality (AHQR). National health care quality report. 2008 .
6. Dincer HE, Lipchik RJ. The intricacies of pneumothorax. Postgrad Med. 2005;118(6) (online article) .
7. Chestnutt MS, Murray JA, Gifford AH, Prendergast TJ. Pulmonary disorders. In: McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis & Treatment. 49th ed. Philadelphia, PA: McGraw-Hill; 2010.
© 2011 Lippincott Williams & Wilkins, Inc.