Hospital Harm: Pneumothorax

Overview

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

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.*

§ 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).

Importance to Patients and Families

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. After being treated for a collapsed lung with a tube, chances of having a recurrence is low, but possible. Patients should avoid scuba diving and flying in a plane for at least 72 hours.

Patient Story

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.

Success Stories

In an academic tertiary care hospital, an interprofessional team including physicians, nurses, and administrative leaders improved and sustained a reduction in iatrogenic pneumothoraces. This was done by implementing clinical documentation standards, cognitive aids, simulation training, purchase/employment of ultrasound equipment, and feedback to clinical services. The role of interprofessional communication and care coordination between health professionals cannot be understated when considering patient outcomes (Shieh et al., 2015).