Haemorrhage after pneumothorax aspiration
I read with interest the case reports on haemorrhage after aspiration for spontaneous pneumothorax.1
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 two 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 with 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 admit to going back to the 2ICS MCL approach, which I find much easier. While 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 seem 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 puncture the chest wall is of a comparatively small calibre. It would be a rare occurrence to cause a massive haemothorax even when deliberately puncturing subclavian vessels for central venous access, so it does seem incredibly unlucky to have three cases in such a short period of time.
