Incidence Of Iatrogenic Pneumothorax Research Articles

Puncture frequency predicts pneumothorax in preoperative computed tomography-guided lung nodule localization for video-assisted thoracoscopic surgery.

BackgroundIatrogenic pneumothorax is the most frequent complication in preoperative CT‐guided localization (POCTGL) of lung nodules. We aimed to determine the predictive factors of iatrogenic pneumothorax.MethodsWe retrospectively analyzed data of consecutive POCTGL procedures in patients who received video‐assisted thoracoscopic surgery (VATS) at our hospital between May 2015 and October 2019. All of our patients utilized laser angle guide assembly to aid in the localization procedures.ResultsIn 610 consecutive POCTGL procedures, 40 (6.6%) patients developed iatrogenic pneumothorax, and complications occurred in 8.5%. Univariate analyses revealed that puncture frequency, male gender, puncture depth, left decubitus position, and nodule near fissure were factors associated with pneumothorax, while multivariate analysis showed that only male gender (odds ratio 3.58, p = 0.012) and puncture frequency (odds ratio 2.39/time, p = 0.0004) determined development of pneumothorax. Further collective analysis on puncture frequency revealed that tumor in a difficult zone (1.33 ± 0.71 vs. 1.19 ± 0.45, p = 0.002), especially adjacent to the mediastinum (1.41 ± 0.75 vs. 1.21 ± 0.52, p = 0.002), angle difference of plan‐to‐practice (r = 0.209, p = < 0.001), depth to skin (r = 0.152, p < 0.001), and depth to pleura (r = 0.164, p < 0.001) were factors related to increased puncture frequency in univariate analyses. Only angle difference of plan‐to‐practice was associated in multivariate analysis (odds ratio: 1.158, p = 0.008).ConclusionsPuncture frequency was the key factor in the development of iatrogenic pneumothorax from POCTGL. Other associated factors, especially angle difference, may have affected the puncture frequency and subsequently have some influence on the incidence of iatrogenic pneumothorax.

HOSPITAL TEACHING STATUS ON THE INCIDENCE OF POSTPROCEDURAL PNEUMOTHORAX: A RETROSPECTIVE NATIONAL IN-PATIENT SAMPLE STUDY

TOPIC: Procedures TYPE: Original Investigations PURPOSE: Postprocedural pneumothorax (iatrogenic) is a patient safety indicator resulting from invasive procedures such as insertion of subclavian central line, pacemaker/ implantable cardiac defibrillator (ICD) placement, transbronchial lung biopsy and transthoracic pulmonary biopsy. This study examines if any of these invasive procedures have a higher predisposition to iatrogenic pneumothorax in teaching hospitals as compared to non-teaching hospital. METHODS: Cohort of patients aged 18 or older who had percutaneous lung biopsy, trans-bronchial lung biopsy, subclavian central line placement, and pacemaker/ICD placement were identified from the National Inpatient Sample (NIS) database from the years 2016 to 2017 using ICD 10-procedure codes. Diagnosis of iatrogenic pneumothorax was identified using ICD 10 – diagnosis code. Incidence of post-procedural pneumothorax were estimated for overall hospital encounter and for each of the procedures. The incidence rate was compared between teaching hospital group (TH) and non-teaching hospital (NTH) using chi-square statistical test. Odds ratio (OR) comparing both group were estimated with logistic regression. RESULTS: Iatrogenic pneumothorax was identified in 2,951 of 13,575 (21.7%) transthoracic lung biopsy, with 21.6% in TH group vs 22.1% in NTH group ( OR 0.96, 95% CI 0.88 – 1.05, p = 0.41). Among patients who had trans-bronchial lung biopsy, post-procedural pneumothorax occurred in 890 out of 26,793 (3.3%) with 3.6% in TH vs 2.6% in NTH ( OR 1.37, 95% CI 1.17 – 1.59, p = <0.001). Across 568,677 subclavian central line insertions, incidence of post-procedural pneumothorax was also higher in TH group (0.43% in TH vs 0.34% in NTH, OR 1.26, 95% CI 1.15 – 1.39, p = <0.001). Pacemaker/ICD placement in 83,033 patients resulted in 1.17% incidence of iatrogenic pneumothorax in TH vs 1.44% in NTH (OR 0.81, 95% CI 0.71 – 0.92, p = 0.02). Overall, a total of 18,703 cases of iatrogenic pneumothorax out of the 14 million (unweighted) hospital admissions were identified between 2016 to 2017 with incidence of 144 events per 100,000 hospital encounters in the TH group and 103 events per 100,000 hospital encounters in the NTH. CONCLUSIONS: Our study showed a significantly higher incidence of post-procedural pneumothorax in teaching hospitals among patients undergoing trans-bronchial lung biopsy and subclavian central line insertion. And a lower incidence in patients undergoing pacemaker/ICD placement. Incidence of iatrogenic pneumothorax in patients undergoing transthoracic lung biopsy was not significantly different between the two groups. Overall, iatrogenic pneumothorax was more prevalent in teaching hospitals. Randomized controlled studies are needed to identify the etiology of our findings. CLINICAL IMPLICATIONS: Our study raises the concern that physicians-in-training due to lack of experience may be a major factor accounting for a higher incidence of iatrogenic pneumothorax in teaching hospital DISCLOSURES: no disclosure on file for Tewabe Belay; No relevant relationships by Sahai Donaldson, source=Web Response no disclosure on file for Daniel Larbi; No relevant relationships by Alem Mehari, source=Web Response No relevant relationships by Richard Ogunti, source=Web Response No relevant relationships by Lamiaa Rougui, source=Web Response No relevant relationships by Mahbubur Sumon, source=Web Response

IDENTIFICATION OF RISK FACTORS FOR IATROGENIC PNEUMOTHORAX DURING BRONCHOSCOPY WITH TRANSBRONCHIAL LUNG BIOPSIES

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: Transbronchial lung biopsies (TBLB) have become essential in the evaluation of a variety of pulmonary pathologies since they were first described in 1974. Performing TBLB during fiberoptic bronchoscopy increases the risk of complications; particularly bleeding and pneumothorax. The incidence of iatrogenic pneumothorax (IP) with TBLB is approximately 1-6%. The goal of our study is to evaluate risk factors such as positive pressure ventilation that could contribute to an increase in the incidence of IP. METHODS: We performed a retrospective cohort study of patients that underwent bronchoscopy at University of Missouri Hospital between 2015 and 2018. Patient demographics, bronchoscopy procedure details, sedation type, and complications were collected via chart review. Statistical analysis was performed to identify factors associated with an increased risk of iatrogenic pneumothorax. RESULTS: We queried 835 bronchoscopies performed at our institution over the four years. The majority of cases were elective outpatient procedures 70.3%. Most of the bronchoscopies were performed with elective mechanical ventilation (72.66%), and transbronchial biopsies were performed in 41.8% of the cases. The overall rate of IP was 1.68% (14/835) with 71.43% (10/14) occurring during bronchoscopies with transbronchial biopsies. Nevertheless, statistical analysis did reveal a significant difference in IP with TBLB or mechanical ventilation. The rate of IP with TBLB performed with positive pressure ventilation versus without positive pressure ventilation also failed to exhibit a statistically significant difference; 2.6% (7/269) versus 0.92% (3/327), respectively (p = 0.117). The rate of IP was significantly higher in patients that underwent TBLB of more than one lobe (13.04% vs. 1.91%, p = 0.003). History of COPD, the presence of emphysema, and tobacco dependence did not exhibit a significant difference in the rate of IP. The use of navigational bronchoscopy, fluoroscopic guidance, and brushings also failed to show a statistically significant difference. CONCLUSIONS: The majority of pulmonologists consider positive pressure ventilation a relative contraindication to transbronchial biopsies after several studies demonstrated higher rates of IP (>10%) in patients requiring mechanical ventilation. More recently, studies evaluating the risk of pneumothorax in patients undergoing TBLB with elective mechanical ventilation have not demonstrated an increased risk of IP. Our findings add further substantiation to the literature by also showing no significant increase in the risk of IP when TBLB are performed during bronchoscopy with elective mechanical ventilation. CLINICAL IMPLICATIONS: Our cohort demonstrates a significant increase in the risk of IP in patients that undergo TBLB of more than one lobe. More importantly, it shows no significant increase in the risk of IP form TBLB with elective mechanical ventilation. DISCLOSURES: No relevant relationships by Ethan Karle, source=Web Response No relevant relationships by Armin Krvavac, source=Web Response No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by AMANBIR SOHAL, source=Web Response No relevant relationships by Jason Zweig, source=Web Response

Incidence of iatrogenic pneumothorax following acupuncture treatments in Taiwan.

Pneumothorax is a rare complication of acupuncture and the risk factors are unclear. This study analysed the incidence of post-acupuncture pneumothorax requiring hospitalisation in a one-million-sample cohort derived from Taiwan's National Health Insurance Research Database. We tracked this cohort between 1997 and 2012 and recorded all medical insurance information. Subjects were categorised according to gender, insurance amount, comorbidities, residential area, and number of acupuncture treatments. Pneumothorax risk was evaluated according to different demographic and medical variables by logistic regression analysis using an adjusted odds ratio (aOR) with a 95% confidence interval (95% CI). Overall, 411 734 patients undergoing 5 407 378 acupuncture treatments were identified with data collected over the first 7 days after acupuncture. The incidence rates of iatrogenic pneumothorax were 0.87 per 1 000 000 acupuncture treatments overall and 1.75 per 1 000 000 acupuncture treatments in "at-risk" anatomical areas. Multivariate logistic regression demonstrated that a history of thoracic surgery (aOR 7.85, 95% CI 3.49 to 9.25), chronic bronchitis (aOR 2.61, 95% CI 1.03 to 6.87), emphysema (aOR 4.87, 95% CI 1.03 to 7.96), pneumonia (aOR 2.09, 95% CI 1.44 to 2.72), tuberculosis (aOR 3.65, 95% CI 1.39 to 9.56), and lung cancer (aOR 3.85, 95% CI 1.53 to 9.73) may increase the post-acupuncture risk of iatrogenic pneumothorax. Men had a higher risk of pneumothorax than women (aOR 3.41, 95% CI 1.36 to 8.57). The number of treatments was not associated with risk of pneumothorax. Patients with a history of lung disease including chronic bronchitis, emphysema, tuberculosis, lung cancer and pneumonia, and a history of thoracic surgery, might have an increased post-acupuncture risk of pneumothorax. This information may possibly help physicians avoid post-acupuncture pneumothorax.

Factors Associated with Inpatient Thoracentesis Procedure Quality at University Hospitals

Physicians increasingly refer thoracentesis procedures to interventional radiology (IR) rather than performing them at the bedside. Factors associated with thoracentesis procedures at university hospitals were studied to determine clinical outcomes by provider specialty. An administrative database review was performed of patients who underwent an inpatient thoracentesis procedure in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through September 2013. The incidence of iatrogenic pneumothorax, mean total hospital costs, and mean length of stay (LOS) were compared by clinical specialty. There were 113,860 admissions with 132,472 thoracentesis procedures performed on 99,509 patients at 234 UHC hospitals. IR performed 43,783 (33%) thoracentesis procedures; medicine, 22,243 (17%); and pulmonary, 26,887 (20%). The incidence of iatrogenic pneumothorax was 2.8% for IR, 2.9% for medicine, and 3.1% for pulmonary. Medicine and pulmonary had equivalent risk of iatrogenic pneumothorax compared to IR after controlling for clinical covariates. Admissions with medicine and pulmonary procedures were associated with significantly lower costs compared to IR admissions (p < 0.001) after controlling for clinical covariates. Admissions with IR procedures had a mean LOS of 14.1 days; medicine, 13.2 days; and pulmonary, 15.9 days. Admissions with medicine and pulmonary procedures were associated with fewer hospital days when compared to IR in the controlled model (p < 0.001). Admissions with medicine and pulmonary bedside thoracentesis procedures are as safe and less costly than IR procedures. Shifting IR thoracentesis procedures to the bedside might be a potential way to reduce hospital costs while still ensuring high-quality patient care, provided that portable ultrasound is used.

Interruption of Chest Compression for Central Venous Catheterization during Cardiopulmonary Resuscitation

*Background: Peripheral venous catheterization (PVC) is a less invasive and time consuming technique than central venous catheterization (CVC); however, for patients in circulatory collapse or receiving cardiopulmonary resuscitation (CPR), PVC cannot be achieved easily. CVC can provide not only a more effective administration route for medication, but also important hemodynamic information. Owing to the possibility of CPR interruptions and complications, CVC is recommended only after the failure of PVC. This observational study is aimed to evaluate the risks and benefits of CVC during CPR. Methods: This retrospective observational study was performed in the emergency department (ED) of a university hospital. Adult patients without a pulse on arrival were consecutively enrolled if subclavian CVC was performed at the beginning of CPR. Patients who already had an established intravenous route or had severe chest injuries on arrival were excluded. Closed-circuit television was used to evaluate the frequency of compression interruption. The incidence of iatrogenic pneumothorax, an acute mechanical complication associated with subclavian CVC, was investigated using chest X-ray after CPR. Results: During a 6-month period, 35 patients underwent CPR and 31 of these received subclavian CVC. Among the patients, one patient experienced iatrogenic pneumothorax (3.8%), and 13 CPR interruptions occurred in 10 subjects during subclavian CVC. Conclusions: During CPR in 31 patients, one iatrogenic pneumothorax was caused by subclavian CVC, and CPR interruptions were observed in approximately 30% of cases.

Sonography of iatrogenic pneumothorax in pediatric patients.

Pneumothorax is defined as the presence of air in the pleural cavity. The incidence of iatrogenic pneumothorax in the pediatric population is 0.3–0.48 in 1000 patients. A conventional chest X-ray, in some cases supplemented with chest computed tomography, is a typical imaging examination used to confirm the diagnosis of pneumothorax. Within the last years, the relevance of transthoracic lung ultrasound in the diagnostic process of this disease entity has greatly increased. This is confirmed by the opinion of a group of experts in ultrasound lung imaging in patients in a life-threatening condition, who strongly recommend a transthoracic ultrasound examination for the diagnosis of pneumothorax in such patients. These data constituted the basis for initiating the prospective studies on the application of this method in pneumothorax diagnosis in patients of pediatric hematology and oncology wards.AimThe aim of the study was to present the possibility of using the transthoracic lung ultrasound in the diagnostic process of pneumothorax in pediatric patients, with particular attention paid to its iatrogenic form. The article discusses sonographic criteria for pneumothorax diagnosis in pediatric patients, including the sensitivity and specificity of the method, in relation to conventional chest X-ray.Material and methodsThe prospective studies included a group of patients treated in the Clinic of Pediatrics, Pediatric Hematology, Oncology and Endocrinology of the Academic Clinical Centre (Medical University of Gdańsk, Poland) in whom a central venous catheter was placed in the subclavian veins. The studies lasted for one year – from 1 July 2011 to 30 June 2012. The examined group comprised 63 patients – 25 girls (39.7%) and 38 boys (60.3%) aged from 1 to 17. The analysis included the results of 115 ultrasound examinations conducted in this group.ResultsIn t he examined group with suspected or diagnosed neoplasm, iatrogenic pneumothorax was identified in 4 out of 63 patients (6.3%). In all cases, it was a consequence of procedures connected with the introduction of a central catheter. In the examined material, the sensitivity, specificity and predictive values (positive and negative) of the transthoracic lung ultrasound equaled 100%.ConclusionsThe transthoracic ultrasound examination is a highly effective method in diagnosing iatrogenic pneumothorax in pediatric patients. However, to confirm this conclusion, multicenter studies, among considerably larger populations, are necessary.

Iatrogenic pneumothorax: experience of a Moroccan Emergency Center

The incidence of iatrogenic pneumothorax (IPx) will increase with invasive procedures particularly at training hospitals, which is why we have made a retrospective study of the common diagnostic or therapeutic causes of IPx and its impact on morbidity. From January 2011 to December 2012, 36 patients developed IPx as emergencies, after an invasive procedure .Their mean age was 38 years (range: 19-69 years). Of the patients, 21 (58%) were male and 15 (42%) were female. The purpose was diagnostic in 6 cases and therapeutic in 30 cases. In 8 patients (22%) the procedure was performed due to underlying lung diseases and in 28 patients (78%) for other diseases. The procedure most frequently causing IPnx was central venous catheterization, with 20 patients (55%), other frequent causes were mechanical ventilation, 8 cases (22%) of whom we reported 3 cases of bilateral pneumothorax, 6 cases of thoracentesis (16%) and 2 patients had life-saving percutaneous tracheotomy. The majority of our patients were managed by a small chest tube placement (unilateral n=30, bilateral n=3).The average duration of drainage was 3 days (range: 1-15 days), sadly one of our patients died of ischemic brain damage 15 days after tracheotomy.At training hospitals the incidence of IPnx will increase with the increase in invasive procedures, which should only be performed by experienced personnel or under their supervision.

Iatrogenic pneumothorax: Experience of a Moroccan Emergency Center

The incidence of iatrogenic pneumothorax (IPx) will increase with invasive procedures particularly at training hospitals, that is why we have made a retrospective study of the common diagnostic or therapeutic causes of IPx and its impact on morbidity. From January 2011 to December 2011, 36 patients developed IPx as emergencies, after an invasive procedure. Their mean age was 38 years (range: 19–69 years). Of the patients, 21 (58%) were male and 15 (42%) were female. The purpose was diagnostic in 6 cases and therapeutic in 30 cases. In 8 patients (22%) the procedure was performed due to underlying lung diseases and in 28 patients (78%) for other diseases. The procedure most frequently causing IPnx was central venous catheterization, with 20 patients (55%), other frequent causes were mechanical ventilation in 8 cases (22%) (of whom we reported 3 cases of bilateral pneumothorax), 6 cases of thoracentesis (16%) and 2 patients had life-saving percutaneous tracheotomy. The majority of our patients were managed by a small chest tube placement (unilateral n=30, bilateral n=3). The average duration of drainage was 3 days (range: 1–15 days), sadly one of our patients died of ischemic brain damage 15 days after tracheotomy.At training hospitals the incidence of IPnx will increase with the increase in invasive procedures, which should only be performed by experienced personnel or under their supervision.

Iatrogenic Pneumothorax: Etiology, Incidence and Risk Factors

We discuss the etiology and incidence of iatrogenic pneumothorax (IPnx) which can develop after invasive procedures performed for diagnostic and/or therapeutic purposes, and the efforts to prevent this complication and its consequences. The records of patients who were treated for the diagnosis of IPnx between December 1998 and December 2006 were retrospectively reviewed. The patients were evaluated according to their age, gender, the procedure which caused IPnx, the department which performed the procedure, the treatment and its consequences. 12 010 invasive procedures were performed in our hospital during the period and 164 patients (1.36 %) developed IPnx. Their mean age was 49.27 (range: 8 months-93 years). Of the patients, 101 (61 %) were male and 63 (39 %) were female. The 56.7 % of the invasive procedures which caused IPnx were performed under emergency conditions and 43.3 % were performed under elective conditions. In 69 patients (42 %) the procedures were performed due to underlying lung diseases and in 95 patients (58 %) for diseases other than lung diseases. The most frequent procedure type causing IPnx was central venous catheterization, with 72 patients (43.8 %). The other frequent causes were thoracentesis with 33 patients (20.1 %) and barotrauma due to mechanical ventilation with 15 patients (9.1 %). At training hospitals the incidence of IPnx will increase in parallel to the increase in invasive procedures. Invasive procedures should be performed by experienced personnel or under their supervision when risk factors are involved.

Pneumothorax in the Intensive Care Unit

The risk factors and outcomes of critically ill patients with iatrogenic pneumothorax (IP) have not been studied in a large unselected intensive care unit (ICU) population. The authors studied a prospective cohort of adults admitted for more than 24 h. Data were collected at ICU admission and daily by senior physicians until ICU discharge. Risk factors for IP were identified in the entire cohort. A matched nested case-control study was used to evaluate the excess risk of IP in decedents. Of the 3,499 patients, 69 with pneumothorax before ICU admission were excluded. Of the remaining 3,430 patients, 94 experienced IP within 30 days (42 due to barotrauma and 52 due to invasive procedures). The cumulative incidence of IP was 1.4% (95% confidence interval [CI], 1.0-1.8) on day 5 and 3.0% (95% CI, 2.4-3.6) on day 30. Risk factors for IP (hazard ratio [95% CI]) were body weight less than 80 kg (2.4 [1.3-4.2]), history of adult immunodeficiency syndrome (2.8 [1.2-6.4]), diagnosis of acute respiratory distress syndrome (5.3 [2.6-11]) or cardiogenic pulmonary edema at admission (2.0 [1.1-3.6]), central vein or pulmonary artery catheter insertion (1.7 [1.0-2.7]), and use of inotropic agents during the first 24 h (2.1 [1.3-3.4]). Excess risk of IP in decedents was 2.6 (95% CI, 1.3-4.9; P = 0.004). Iatrogenic pneumothorax is a life-threatening complication seen in 3% of ICU patients. Incorporating risk factors for IP into preventive strategies should reduce the occurrence of IP.