Tension Pneumomediastinum: An iatrogenic complication of a malpositioned chest tube
Background: Chest tube malposition i.e. intrafissural or intraparenchymal placement has been associated with thoracic or abdominal organ injuries (perforation, laceration, or compression). However extensive tension pneumomediastinum as a complication of chest tube placement has not been previously reported.
Case: We report a case of severe symptomatic spontaneous pneumothorax in a patient with bullae. Percutaneous placement of chest tube with a trocar in the emergency department led to traumatic extensive tension pneumomediatinum and subcutaneous emphysema. Thoracic CT scan confirmed intrafissural placement of chest tube with the tip extending to the mediastinum. Prompt recognition and intrapleural placement of second chest tube led to rapid regression of tension pneumomediastinum.
Conclusion: Malposition is a known complication of percutaneous placement of chest tube. Early recognition of complications with CT thorax and prompt action are critical in preventing life threatening complications.
A 50 year old male was hospitalized with a 2 day history of fever, productive cough with yellowish sputum, mild pleuritic chest pain and dyspnea. Significant medical history included HIV infection acquired by intravenous drug use, Hepatitis B and C infection, systemic Hypertension and Diabetes mellitus-type 2. He also had history of prior treatment for pneumocyctis jiroveci pneumonia and pulmonary tuberculosis. He was non-compliant with his anti retroviral medications and an active cigarette smoker of 10 pack years. Vital signs were normal except for mildly elevated blood pressure and oxygen saturation was 97% on room air. Physical examination was notable for a deviated trachea to left side, with diminished air entry and hyper resonance on the right side of the chest. Admission plain chest radiograph (Fig.1) revealed right sided large pneumothorax, contralateral mediastinal shift, and right apical bullae. Chest tube with trocar was emergently placed in the right hemithorax in the ER. Post tube thoracotomy chest radiograph showed complete re-expansion of lung parenchyma, right apical bullae and mild subcutaneous emphysema.
Over next eighteen hours following chest tube insertion, patient developed extensive subcutaneous emphysema extending to the eyelids, as well as to the abdomen. A contrast enhanced thoracic CT scan (Figs. 2 & 3) showed massive subcutaneous as well as mediastinal emphysema. The chest tube was in the major fissure and the tip extending into the mediastinum (Fig.4). Serial plain chest X-ray films showed progression of subcutaneous emphysema with a small stable apical pneumothorax. Over the next 6 hours, patient developed severe respiratory distress and hypotension. He was emergently intubated and a second chest tube was inserted to help decompress pneumomediastinum. Subsequently he underwent video assisted right sided thoracoscopy and bullectomy of right upper lobe.
Fig 1. Chest X-ray PA view Fig 2. CT scan of chest Coronal view
Fig 3. CT scan of chest Saggital view Fig 4. CT scan showing intrafissural tube placement
Percutaneous chest tube insertion is routinely performed to treat symptomatic pneumothorax. The incidence of chest tube malposition based on chest radiographs alone, is less than 3% in trauma patients [ 1,2,4,5 ] and in patients hospitalized in medical critical care unit or internal medicine service. Chest tube malposition, i.e intrafissural, intraparenchymal placement has been associated with thoracic or abdominal organs injuries (perforation, laceration, or compression).
Three prior studies have reported a greater incidence of serious events complicating chest tube malposition. One autopsy study revealed two lung lacerations in 18 patients with percutaneous chest tubes. In 51 trauma patients who had emergent tube thoracostomy performed in the emergency room, thoracic computed tomography (CT) demonstrated a malposition rate of 26% (including 7% intraparenchymal and 12% intrafissural tubes). In another study, CT assessment of pleural drainage in 26 patients with empyema [8, 9] identified three intraparenchymal and eight intrafissural tubes. In these studies, frontal radiographs failed to recognize chest tube malposition, whereas CT correctly identified the malposition of chest tube. A French prospective study of 106 patients who had chest tube placement for pneumothorax / pleural effusion, malposition was noted in 32 of 106 chest tubes (30.2%): 22 were intrafissural (20.8%) and 10 were intraparenchymal (9.4%). The only parameter significantly linked to an increased incidence of malposition was the use of a trocar . Intrafissural, intraparenchymal tubes were inefficient in drainage of air or pleural effusion and required a new drainage .
Complications Resulting from Chest Tube Malposition: Morbidity of intrafissural chest tubes is poorly described, but severe complications have been reported, such as bronchiolar erosion necessitating thoracotomy  , right pulmonary artery branch injury. Complications resulting from intraparenchymal insertion of chest tubes include life-threatening bronchopleural fistula necessitating thoracotomy  , lung abscess necessitating lobectomy  , and lung bleeding necessitating thoracotomy , but may remain totally asymptomatic [6, 12]. Pleural adhesions are classically considered as a risk factor for chest tube malposition [1, 6, 13-15]. In fact, the thoracic drainage technique played a key role in the incidence of chest tube malposition. The deleterious role of a trocar has been previously suspected [1, 16-18]. A tube in a rigid metallic trocar is by itself, more susceptible to cause lung injury than a flexible tube directly inserted in the pleural space . In our patient, thoracic CT scan confirmed intrafissural placement of chest tube in the right major fissure extending to the mediastinum and in close proximity to right upper lobe bullae. Though there was a significant resolution of right pneumothorax, rapidly progressive subcutaneous and mediastinal emphysema was noted, which resulted in hemodynamic compromise. The earlier chest tube was ineffective in draining air. A properly positioned second chest tube was required to drain air from the mediastinum and relieve tension and resolve hypotension.
The incidence of chest tube malposition confirmed on a thoracic CT scan is as high as 30% in critically ill patients. Major risk factor for malpostioned tube is the use of a trocar instead of blunt dissection and insertion of a flexible tube and pleural adhesions. Malpositioning of chest tube should be suspected if there is worsening of pneumothorax or development of new complications like pneumomediastinum or subcutaneous emphysema. Frontal projection of Chest X-ray is insensitive to diagnose chest tube malposition. Thoracic CT imaging can help identify complications of malpositioned chest tube. Prompt repositioning of the chest tube in the pleural space in such cases definitely can help to improve the outcome.
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