June 2011, Volume 41 Number 6 , p 66 - 67
MR. S HAS JUST returned to your unit following a transbronchial biopsy (TBB) of a left upper lobe (LUL) lung mass. Your initial assessment findings include equal, clear breath sounds and a SpO2 of 94% on room air. Other than the LUL mass, his postprocedure supine chest X-ray is normal.A half hour later, you find him in respiratory distress with a SpO2 of 82% and markedly diminished breath sounds on the left. He states he started having left-sided chest pain and trouble breathing about 15 minutes earlier but thought it would get better on its own. You suspect that Mr. S may have an iatrogenic pneumothorax and immediately activate the rapid response team.An iatrogenic condition is induced by a medical treatment or procedure. This article discusses risk factors associated with iatrogenic pneumothorax, as well as patient assessment and management. But first, consider the causes.An iatrogenic pneumothorax occurs when air enters the pleural space during a medical treatment or procedure, such as Mr. S's TBB. (See What can cause an iatrogenic pneumothorax?) If a small amount of air enters the pleural space, the patient may be asymptomatic, but larger amounts of air can cause a partial or complete lung collapse. The result is decreased vital capacity and Sao2. Potential complications include tension pneumothorax, the accumulation of air in the pleural space causing mediastinal shift and circulatory collapse. This is a medical emergency requiring immediate intervention.A patient who's on positive pressure ventilation or who's hemodynamically unstable must be treated immediately with a needle chest decompression followed by chest tube insertion. In severe cases, even a short delay to obtain an X-ray or to place chest tube can be fatal.The good news is that the incidence of iatrogenic pneumothorax has decreased from more than 20% in the 1990s to approximately 3%.1Be vigilant in monitoring your patient for iatrogenic pneumothorax following any procedure known to increase the risk.