Bronchoalveolar Lavage (BAL): very low risk of pneumothorax
Transbronchial Biopsy (TBB): higher risk of pneumothorax than with BAL
Central Venous Catheter Placement (see Central Venous Catheter, [[Central Venous Catheter]])
Physiology: inadvertent puncture of pleural space during procedure
Clinical Data
French Multi-Center, Randomized Trial Examining Complication Rates of Three Different Central Venous Catheter Insertion Sites (NEJM, 2015) [MEDLINE]: multi-center, randomized trial (n = 3471)
Subclavian CVC had 3x Higher Risk of Pneumothorax Requiring Chest Tube Insertion (1.5% of Cases), as Compared to Internal Jugular Sites (0.5% of cases)
Inadvertent Extraluminal Positioning of the Tracheostomy Fenestration During Tracheostomy Placement: for this reason, fenestrated tracheostomies are typically not selected for initial percutaneous tracheostomy placement
Laceration of the Posterior Tracheal Wall
Clinical
Pneumothorax (see Pneumothorax, [[Pneumothorax]]): occurs in 0.6% of cases (Chest, 2004) [MEDLINE]
Subcutaneous Emphysema (see Subcutaneous Emphysema, [[Subcutaneous Emphysema]]): occurs in 1.5% of cases (Chest, 2004) [MEDLINE]
Sensitivity: very sensitive in detecting pneumothorax and can be repeated at bedside multiple times, noninvasively, and quickly
Sliding Sign: normal finding, where the visceral pleura slides against the parietal pleura
In pneumothorax, “sliding” is absent
Lung Point Sign: where, in the presence of pneumothorax, the lung touches the chest wall intermittently
Clinical Manifestations
Cardiovascular Manifestations
Hypotension: may occur with tension pneumothorax
xxxx
Pulmonary Manifestations
Unilateral or Bilateral Pneumothorax
Physiology
Diagnosis
Unilateral Pneumothorax
Bilateral Pneumothorax: may occur in cases with “buffalo chest” (where mediastinum has been previously entered during prior mediastinal surgery, lung transplant, etc) (see Buffalo Chest, [[Buffalo Chest]])
ACCP Recommendation: observation for small spontaneous PTX (<3 cm rim on CXR) and clinical stability
BTS Recommendation: observation for small spontaneous PTX (<2 cm rim on CXR) and clinical stability
Pleurodesis: recommended for patients with second ipsilateral spontaneous pneumothorax
References
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Ultrasonic examination: an alternative to chest radiography after central venous catheter insertion? Am J Respir Crit Care Med. 2001;164(3):403-405 [MEDLINE]
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Clinical applications of bedside ultrasonography in internal and emergency medicine. Intern Emerg Med 2011 Jun;6(3):195-201. doi: 10.1007/s11739-010-0424-3. Epub 2010 Aug 3 [MEDLINE]
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