DELAYED TENSION PNEUMOTHORAX COMPLICATING CENTRAL VENOUS CATHETERIZATION AND POSITIVE PRESSURE VENTILATION

Pneumothorax is the most common complication after central venous cath eterization. The diagnosis of pneumothorax may he delayed for hours or days, in some instances because of minimal clinical symptoms or radio graphic signs on initial evaluation, or in other instances because of late presentation precipitated by positive pressure ventilation. A cas e is presented in which a patient developed a tension pneumothorax whi le under general anesthesia 10 days after central venous line placemen t. A review of the literature suggests that delayed pneumothorax has a n incidence of approximately 0.4% of all central venous access attempt s, is mush more common after subclavian than internal jugular approach es, especially in difficult or multiple attempts, is asymptomatic in 2 2%, and results in tension pneumothorax in 22%. End-expiratory upright chest radiographs, the optimal radiographic technique for detection o f small pneumothoraces, were obtained in only 19% of reviewed cases. S upine views, the least sensitive radiographic technique, should be car efully reviewed for evidence of basilar hyperlucency, a deep sulcus si gn, or a double diaphragm sign. In patients unable to tolerate the upr ight position, supine views should he supplemented with lateral decubi tus, oblique, or cross-table lateral views. Emergency physicians shoul d be aware of the possibility of delayed pneumothorax, as well as opti mal radiographic technique for demonstration of small pneumothoraces, and subtle radiographic findings in supine or semirecubment patients. (C) 1995 by W.B. Saunders Company