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


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.
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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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    • "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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