Managing a Pneumothorax – The Fear is Mostly in the Mind

Two weeks ago, in Beirut, I was speaking on the impact of modern imaging in pulmonary medicine, to a group of chest physicians from Egypt. The moment I started speaking on CT guided lung biopsies, a physician got up and started talking about the dreaded risk of pneumothorax. I have had similar reactions in other towns in India, including tier I cities like Delhi.

I explained to him that while a pneumothorax is not uncommon during CT guided biopsies, there are many ways to mitigate its seriousness; single puncture, minimal trauma, bleeding along the tract during withdrawal and arguably puncture side down for a few minutes are measures that reduce the severity and incidence of or prevent the occurrence of pneumothorax.

But even if a pneumothorax does occur, it is a slow event that takes its own time to increase, if it does. If a pneumothorax occurs during the procedure, it can be aspirated at the same time and more often than not, that cares of the problem and we can even continue with the procedure (Figure 1). In case the pneumothorax occurs after we have washed out as a delayed complication, then we can still aspirate it using an over the needle catheter. A recent video describing this procedure has been posted on The New England Journal of Medicine site. While this video shows the technique to be used in patients with spontaneous pneumothorax and describes a blind approach, we can use this simple procedure to aspirate under CT guidance as well and then check the status immediately on the CT scan table.

A and B show the start of a CT guided core biopsy of a subpleural nodule using a coaxial system. Since the nodule is immediately subpleural, the risk of pneumothorax is slightly higher than for a deeper nodule and C shows the developing pneumothorax. In D, the canula has been withdrawn into the pleural space and the pneumothorax was aspirated. E shows the biopsy continuing after the pneumothorax has been aspirated. It did not recur. Five minutes after the procedure, a scan in the supine position (G) shows a thin residual pneumothorax that was non-progressive.

A and B show the start of a CT guided core biopsy of a subpleural nodule using a coaxial system. Since the nodule is immediately subpleural, the risk of pneumothorax is slightly higher than for a deeper nodule and C shows the developing pneumothorax. In D, the canula has been withdrawn into the pleural space and the pneumothorax was aspirated. E shows the biopsy continuing after the pneumothorax has been aspirated. It did not recur. Five minutes after the procedure, a scan in the supine position (G) shows a thin residual pneumothorax that was non-progressive.

In the worst case scenario, an interventional radiologist should be able to put a tube in as well, despite the fact that the need to do this would be very low in experienced hands.

Comments

  1. anup sadhu says:

    I have the similar experience! Usually pneumothorax during guided procedure can be managed in the department without tubing.In a smaller number of pts water-seal may be required.That’s not very tough .Hagga has complication rate of 25%—- –5% needed tubing( Hyderabad 2003-04)!!

  2. Veena Puranik says:

    We tend to have thin rim of pneumothorax for quite a few patients which can resolve on their own.Occasionally some biopsies may develop moderate pneumothorax .We manage by putting in a 12 F pigtail drain on the ct table itself.Many a times we also go ahead with the biopsy if the biopsy needle is already in lung parenchyma.(UK)

  3. Dr. Niraj kumar says:

    I have faced similar type of problem while dealing with empyma thoracic of my younger brother . Surgeon and pyscian has advised for operative proceddure VACT not even suggesting for aspiration in one of the famous hospital in mumbai.
    I decided to aspirate in my clinic back in Jamshedpur and put him on antibiotic . In the 4-5 sittings of aspiration at the inerval of 4-5 days with antibiotic coverage with ATT and good pulmonary excercise complete resolution was noted in one month.

    No pneumothorax or any complication noted..

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