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Re: Simple aspiration of spontaneous pneumothorax using the anterior approach: complication rate

Dear EDitor

I read with interest the report of Rawlins and colleagues,[1] which gave account of 3 cases in which life threatening haemorrhage was associated with anterior needle aspiration of pneumothorax.

The authors commented that data on complications of needle aspiration in spontaneous pneumothorax were limited. They cited one study on traumatic pneumothorax in which needle aspiration was associated with a low complication rate. There are at least 6 more studies in the literature that report low complication rate with simple aspiration using the anterior approach (second intercostal space, mid-clavicular line).[2-7] Haemorrhage was reportedly very rare.

In the authors' institution, 3 cases with haemorrhage occurred over a 6 month period. I would be interested to know the number of cases over the same period in which simple aspiration was successful, and uncomplicated.

References

(1) Rawlins R, Brown KM, Carr CS, Cameron CR. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J 2003;20:383-384.

(2) Noppen M, Alexander P, Driesen P, et al. Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax. A multicenter, prospective, randomised pilot study. Am J Respir Crit Care Med 2002;165:1240-1244

(3) Harvey J, Prescott RJ. Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with healthy lungs. BMJ 1994;309:1338-9

(4) Soulsby T. British Thoracic Society guidelines for the management of spontaneous pneumothorax: do we comply with them and do they work? J Accid Emerg Med 1998;15(5):317-21

(5) Ng AW, Chan KW and Lee SK. Simple aspiration of pneumothorax. Singapore Med J 1994;35(1):50-2

(6) Markos J, Mc Conigle P, Phillips MJ. Pneumothorax: treatment by small- lumen catheter aspiration. Aust N Z J Med 1990;20:775-781

(7) Hayes JA, Burdon JGW. The management of spontaneous pneumothorax by simple aspiration. Aust Fam Physician 1988; 17:458-462.

Send letter to journal:
Re: Haemorrhage after pneumothorax aspiration

Dear Edito

I read with interest the case reports on massive intrathoracic haemorrhage after aspiration for spontaneous pneumothorax.

It has always been my understanding that the reason for continuing to use the second intercostal space, mid-clavicular line (2ICS MCL) approach for these patients is more to do with convenience and ease of approach than for any scientific reason. Aspirating 2 litres may take considerable time, and using the 2ICS MCL it is generally easy to find the intercostal space and the patient can be in pretty much any position that is comfortable for them and convenient for the 'aspirator'. I would contrast this to the 5th intercostal space anterior axillary line approach, when it can be more difficult to identify the space and awkward for both patient and doctor to keep the arm in a convenient position. I tried this approach for a while and have to admit to going back to the 2ICS MCL approach which I find much easier. Whilst tempting to blame the anatomy and dangerous 'big vessels' on each of the cases presented, in none of them was a source of bleeding identified. It is therefore not possible to conclude, as the authors appear to, that similar complications would not occur if a different approach occurred.

I would also be interested to know what technique was used for aspiration - with modern purpose designed seldinger technique kits (or just an old fashioned single lumen cvp line kit) the needle used to punture the chest wall is of a relatively small calibre. It would be a rare occurence to cause a massive haemothorax even when deliberately puncturing subclavian vessels for central venous access, so it does seem incredibly unlucky to have 3 cases in such a short period of time.

Reference

(1) R Rawlins, KM Brown, CS Carr, CR Cameron. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J 2003;20:383-384.