Jump to comment:

• commonsense, supervision, and other issues
  oscar,m jolobe
  Published on: 3 March 2010

• Published on: 3 March 2010

  commonsense, supervision, and other issues

  • oscar,m jolobe, retired geriatrician

  In addition to its use for "safe pleural intervention such as aspirating small effusions"(1), thoracic ultrasound(TUS), when compared with usual practice, has been shown to mitigate the risk of iatrogenic pneumothorax(odds ratio(OR) 0.3; 95% Confidence Interval(CI), 0.2 to 0.7)when utilised as an adjunct, not only to diagnostic thoracentesis(presumably in the context of small effusions), but also as an adjunct to therap...

  Show More

  In addition to its use for "safe pleural intervention such as aspirating small effusions"(1), thoracic ultrasound(TUS), when compared with usual practice, has been shown to mitigate the risk of iatrogenic pneumothorax(odds ratio(OR) 0.3; 95% Confidence Interval(CI), 0.2 to 0.7)when utilised as an adjunct, not only to diagnostic thoracentesis(presumably in the context of small effusions), but also as an adjunct to therapeutic thoracentesis(2). In a systematic review and meta-analysis of 24 studies which reported pneumothorax rates following 6605 thoracentesis, the authors documented that, if anything, pneumothorax was more likely following therapeutic thoracentesis than diagnostic thoracentesis(OR, 2.6; 95% CI,1.8 to 3.8)(2). The risk of pneumothorax was greater when larger needles or catheters were used as opposed to smaller needles(OR, 2.5;95% CI, 1.1 to 6.0). When catheter use, on its own was compared with the use of smaller needles, the risk of pneumothorax was also higher, but, in this instance, the difference between the two modalities did not reach statistical significance(OR, 1.9; 95% CI, 0.5 to 7.2)(2), and only one study reported leaving indwelling catheters in place for a number of days. Among the 6605 thoracentesis documented in those 24 studies, the overall pneumothorax rate was 6%(CI, 4.6 to 7.8%), and in those instances of pneumothorax, this complication justified insertion of chest drains in 34.6%. TUS, however, was no substitute for commonsense and experience, and also no substitute for supervision of junior staff, judging by the fact that, among 6 studies characterised by 100% of TUS, pneumothorax rates ranged from 0% to 10.7%(2). For example, the fact that development of any symptom (cough, dyspnoea, or chest pain) conferred a markedly higher risk of pneumothorax (OR 26.6; 95% CI, 2.7 to 262.5) implied that the 34.6% rate of requirement for chest drain insertion might have been, at least in part, attributable to failure to recognise that those symptoms signified onset of significantly large pneumothorax. Furthermore, among th 6 studies with 100% use of TUS, the pneumothorax rate was second lowest(ie 1.6%) in the cohort of residents who performed the procedure under supervision. Among the four studies with higher rates of pneumothorax(range 2.6% to 10.7%) notwithstanding 100% use of TUS, none reported supervision of residents as part of good practice(2). These observations resonate with the recognition that, when commonsense is not an adjunct, even senior staff can be guilty of inserting chest drains in the pleural space contra lateral to the effusion(3), and that when juniors report that in some trusts "six in ten missed supervision and opportunities to complete new procedures"(4), this is inexcusable References (1)Medford ARL and Entwistle JJ Indications of thoracis ultrasound in chest medicine an observational study Post grad Med J 2010;86:8-11 (2) Gordon CE., Feller-Kopman D., Balk EM., Smetana GW Pneumothorax following thoracentesis Arch Intern Med 2010;170:332-9 (3)Harris A., O'Driscoll BR., Turkington PM Survey of major complication of intercostal chest drain insertion in the UK Postgrad Med J 2010;86:68-72 (4) Munn F Survey reveals pressure on juniors BMA News Review 27 February 2010

  Conflict of Interest:

  None declared

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top