Pneumothorax after Central Line Placement

Pneumothorax (PTX)

Case 1

Patient needed a TLC (triple lumen catheter) which was placed in the left subclavian vein by the surgical house officer. The CXR after the procedure did not show any evidence of PTX. Next morning on physical exam the patiend did not have air entry on the left side of the chest and a stat CXR was ordered.

CXR showed a left sided sided PTX with a deep sulcus.


Left PTX due to left subclavian line placement

A chest tube was placed with a resolution of the PTX. Subcutaneous emphysema developed around the chest tube insertion place.


Post-PTX Subcutaneous Emphysema

Case 2

This is another case of a PTX after a line placement:

82 yo AAF needed a central line for IVF because she was dehydrated. During an attempt to place an external jugular line, she started to complain of SOB. CXR showed a right-sided PTX.


PTX after an external jugular line. You can also see bullet fragments from previous GSW. There is a HD catheter.


PTX after an external jugular line - a close-up view


Right lung not expanded after a chest tube placement


Right lung expanded, the chest tube is still in place. HD catheter and a left central line in place.


Pneumothorax management

The management of a pneumothorax depends on the clinical presentation.

The goal of treatment is to remove the air from the pleural space and to decrease the likelihood of recurrences.

In general, if the patient is asymptomatic and hemodynamically stable, and the pneumothorax is less than 15 % (PTX % = 100 –(average diameter of lung3/average diameter of hemothorax3), high flow oxygen via 100% non-rebreather mask should be sufficient. Gases move in and out of the capillaries in the pleura. The rate of reabsorption depends on the gradient between its partial pressure between the capillaries and the pleural space, the blood flow and the solubility of the gases. The capillary blood carries nitrogen and oxygen among other gases. When 100% O2 is administered, O2 displaces nitrogen and the partial pressure of all the gases in the capillary blood decreases almost 3 times. This leads to a 10 times increase in the gradient for gas absorption compared to room air. This increase in gradient allows for an approximate 4 times increase in the rate of reabsortion of a pneumothorax.

Studies have shown that the rate of spontaneous reabsorption is about 1.2% the volume of the hemithorax per 24 hours. For example, if a patient has a 20% pneumothorax, it will take about 16 days to reabsorbe without oxygen and 4 days with high flow O2.

If the pneumothorax is greater than 15% of the volume of the Hemithorax, and or the patient is hemodynamically unstable (as in tension pneumothorax), or symptomatic, a tube thoracostomy should be performed.

If the patient is hemodynamically unstable and there is clinical suspicion for a pneumothorax (tension pneumothorax), a 16g angiocath should be inserted in the 2nd intercostal space on the suspected site, in the midclavicular line without delaying to confirm the diagnosis with a CXR. Then the patient should be prepared for immediate tube thoracostomy.

References

Central Venous Catheterization: Concise Definitive Review. Medscape, Critical Care Medicine, 05/16/2007 (free registration required).
Improper placement of the central venous catheter - case one and case two from the Annals of Emergency Medicine

Related reading

Subcutaneous Emphysema - GruntDoc.com

Published: 03/12/2004
Updated: 06/01/2010

1 comment:

  1. What is the typical chest well depth (ie 1 1/2" or 2" angiocath) for emergency treatment of a tension pneumo? I read a military medical report on this last year but can't locate it.

    Also how often should this emergency procedure be done in the field (ie by a paradmedic) vs waiting for definitive treatment in the ER. (again I believe one study showed more misses then hits).

    Finally - when would a hemlick (sp?) valve be a good option? (walking chest tube that we have seen placed in a college student by an ER doc recently back from Iraq)

    ReplyDelete