Pneumothorax following thoracentesis: A systematic review and meta-analysis

Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA 02118, USA.
Archives of internal medicine (Impact Factor: 17.33). 02/2010; 170(4):332-9. DOI: 10.1001/archinternmed.2009.548
Source: PubMed

ABSTRACT Little is known about the factors related to the development of pneumothorax following thoracentesis. We aimed to determine the mean pneumothorax rate following thoracentesis and to identify risk factors for pneumothorax through a systematic review and meta-analysis.
We reviewed MEDLINE-indexed studies from January 1, 1966, through April 1, 2009, and included studies of any design with at least 10 patients that reported the pneumothorax rate following thoracentesis. Two investigators independently extracted data on the pneumothorax rate, risk factors for pneumothorax, and study methodological quality.
Twenty-four studies reported pneumothorax rates following 6605 thoracenteses. The overall pneumothorax rate was 6.0% (95% confidence interval [CI], 4.6%-7.8%), and 34.1% of pneumothoraces required chest tube insertion. Ultrasonography use was associated with significantly lower risk of pneumothorax (odds ratio [OR], 0.3; 95% CI, 0.2-0.7). Lower pneumothorax rates were observed with experienced operators (3.9% vs 8.5%, P = .04), but this was nonsignificant within studies directly comparing this factor (OR, 0.7; 95% CI, 0.2-2.3). Pneumothorax was more likely following therapeutic thoracentesis (OR, 2.6; 95% CI, 1.8-3.8), in conjunction with periprocedural symptoms (OR, 26.6; 95% CI, 2.7-262.5), and in association with, although nonsignificantly, mechanical ventilation (OR, 4.0; 95% CI, 0.95-16.8). Two or more needle passes conferred a nonsignificant increased risk of pneumothorax (OR, 2.5; 95% CI, 0.3-20.1).
Iatrogenic pneumothorax is a common complication of thoracentesis and frequently requires chest tube insertion. Real-time ultrasonography use is a modifiable factor that reduces the pneumothorax rate. Performance of thoracentesis for therapeutic purposes and in patients undergoing mechanical ventilation confers a higher likelihood of pneumothorax. Experienced operators may have lower pneumothorax rates. Patient safety may be improved by changes in clinical practice in accord with these findings.

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    • "This study documented the overall rate of pneumothorax-complicated thoracentesis at 6%, with requirement of chest drainage tube insertion in 34.1% of cases (1.7% of all thoracenteses performed). The possibility of instant recourse to ultrasound-guided procedures has been associated to a significantly lower risk of pneumothorax [34]. "
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    ABSTRACT: Chest ultrasonography can be a useful diagnostic tool for respiratory physicians. It can be used to complete and widen the general objective examination also in emergency situations, at the patient’s bedside. The aim of this document is to promote better knowledge and more widespread use of thoracic ultrasound among respiratory physicians in Italy. This document II is focused on advanced approaches to chest ultrasonography especially in diagnosing sonographic interstitial syndrome with physical hypotheses about the genesis of vertical artifacts, differential diagnosis of cardiogenic pulmonary edema and non-cardiogenic pulmonary edema, raising diagnostic suspicion of pulmonary embolism, ultrasound characterization of lung consolidations and the use of ultrasonography to guide procedural interventions in pulmonology. Finally, document II focuses on chest ultrasonography as useful diagnostic tool in neonatal and pediatric care.
    Multidisciplinary respiratory medicine 08/2013; 8(1):55. DOI:10.1186/2049-6958-8-55 · 0.15 Impact Factor
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    • "Iatrogenic PNX is the most common and important complication following pleural puncture [19]. Several risk factors have been identified as the type of needle used [20], the presence of mechanical ventilation, characteristics of the patient as the presence of pulmonary emphysema, operator experience and even the absence of an echographic guide [21,22]. "
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    ABSTRACT: Background: The aim of this study is to evaluate feasibility, safety and efficacy of accessing the pleural space with the patient supine or in lateral recumbent position, under constant ultrasonic guidance along the costophrenic sinus. Methods: All patients with pleural effusion, referred to thoracentesis or pleural drainage from February 2010 to January 2011 in two institutions, were drained either supine or in lateral recumbent position through an echomonitored cannulation of the costophrenic sinus. The technique is described in detail and an analysis of safety and feasibility is carried out. Results: One hundred and one thoracenteses were performed on 76 patients and 30 pigtail catheters were inserted in 30 patients (for a total of 131 pleural procedures in 106 patients enrolled). The feasibility of the procedures was 100% and in every case it was possible to follow real time needle tip passage in the pleural space.Ninety eight thoracenteses (97%) and all catheter drainages were successfully completed. Four thoracenteses were stopped because of the appearance of complications while no pigtail drainage procedure was stopped. After 24 hour follow up, one chest pain syndrome (1.3% of completed thoracenteses) and two pneumothoraces (1.4%) occurred. The mean acquisition time of pleural space was 76 ± 9 seconds for thoracentesis and 185 ± 46 seconds for drainage insertion (p < 0.05). Conclusions: This study highlights the safety and efficacy of this technique of real time echo-monitored pleural space puncture, that offers a more comfortable patient position, an easier approach for the operator, a very low rate of complications with short acquisition time of pleural space.
    Multidisciplinary respiratory medicine 03/2013; 8(1):18. DOI:10.1186/2049-6958-8-18 · 0.15 Impact Factor
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    • "Sonographic imaging enables delineation of structural abnormalities and tissue planes better than superficial anatomic landmarks, allowing invasive procedures to be performed with fewer complications [4]. Real time ultrasound guidance was shown to be the most important factor in lowering the rate of iatrogenic pneumothorax [1]. In one study, ultrasound guided thoracentesis decreased the rate of iatrogenic pneumothorax by 54% [5]. "
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    ABSTRACT: Few internal medicine residency programs provide formal ultrasound training. This study sought to assess the feasibility of simulation based ultrasound training among first year internal medicine residents and measure their comfort at effectively using ultrasound to perform invasive procedures before and after this innovative model of ultrasound training. A simulation based ultrasound training module was implemented during intern orientation that incorporated didactic and practical experiences in a simulation and cadaver laboratory. Participants completed anonymous pre and post surveys in which they reported their level of confidence in the use of ultrasound technology and their comfort in identifying anatomic structures including: lung, pleural effusion, bowel, peritoneal cavity, ascites, thyroid, and internal jugular vein. Survey items were structured on a 5-point Likert scales (1 = extremely unconfident, 5 = extremely confident). Seventy-five out of seventy-six interns completed the pre-intervention survey and 55 completed the post-survey. The mean confidence score (SD) increased to 4.00 (0.47) (p < 0.0001). The mean (SD) comfort ranged from 3.61 (0.84) for peritoneal cavity to 4.48 (0.62) for internal jugular vein. Confidence in identifying all anatomic structures showed an increase over the pre-intervention means (p < 0.002). A simulation based ultrasound learning module can improve the self-reported confidence with which residents identify structures important in performing invasive ultrasound guided procedures. Incorporating an ultrasound module into residents' education may address perceived need for ultrasound training, improve procedural skills, and enhance patient safety.
    BMC Medical Education 09/2011; 11(1):75. DOI:10.1186/1472-6920-11-75 · 1.22 Impact Factor
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