Simple Aspiration of a Pneumothorax Utilizing a Triple-Lumen Catheter

Abstract

To the Editor: Conventional treatment of a simple pneumothorax has been the placement of a large-bore chest tube. We wish to present and expand on an alternative initial approach to these patients--evacuation of free air from the pleural cavity using single- or triplelumen catheters. Many studies have shown both the safety and benefit of treating pneumothoraces via small-lumen catheter aspiration [1-6]. Cost, risk, and hospitalization time may be decreased utilizing this method over larger-lumen chest tubes [1-6]. The following technique describes aspiration using a triple-lumen catheter. This was performed on a patient who suffered an iatrogenic rightsided pneumothorax (approximately 40%-50%) after right subclavian vein puncture. With the patient in the supine position, an 18-gauge intravenous catheter was inserted in the second intercostal space, midclavicular line at an angle of 35 degrees to the skin Figure 1. The catheter was advanced until loss of resistance was felt and aspiration of air was obtained. The needle was then removed, and a guidewire was fed via the catheter into the pleural space. After removal of the 18-gauge catheter over the wire, a triple-lumen catheter was inserted over the wire and fed up to the hub without the use of the dilator. The wire was removed and the distal port capped with a closed stopcock. A 60-mL syringe was connected to the second part of the stopcock. Fluid-filled intravenous tubing was connected to the most proximal port of the catheter and left under water in a 1-L bottle of sterile saline.Figure 1: Insertion of 18-gauge intravenous catheter in the second intercostal space, midclavicular line at an angle of 35 degrees to the skin.The stopcock was opened to the syringe, and 60 mL of intrapleural air was removed. The stopcock was then opened toward the atmosphere, and the 60 mL of aspirated air was easily ejected. This process was repeated on both the distal and middle ports until no further aspiration was possible. The catheter was removed and the puncture site covered with an occlusive dressing. Follow-up serial chest radiographs revealed a 10% pneumothorax, which remained stable and resolved over several days. Current data support catheter aspiration of a simple pneumothorax as a safe and cost-effective technique, with success rates as high as 60%-100% [5]. Chest tube placement may be required for those patients who fail to remain expanded with catheter aspiration, although multiple attempts at catheter drainage have been reported to be successful [6]. The presence of a pleural leak during manual aspiration of air suggests that reexpansion will not be successful and that a more invasive approach may be necessary. Pneumothoraces in patients with bullae, tension pneumothoraces, and active pathologic processes tend to have large persistent air leaks which usually cannot be treated with simple catheter aspiration(s). Zvi Herschman, MD Department of Anesthesiology, St. Barnabas Medical Center, Livingston, NJ 07039 Jeffrey A. Gudin, MD Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510