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Pneumothorax Following Thoracentesis a Systematic Review and Meta-Analysis

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REVIEW ARTICLE Pneumothorax Following Thoracentesis A Systematic Review and Meta-analysis Craig E. Gordon, MD, MS; David Feller-Kopman, MD; Ethan M. Balk, MD, MPH; Gerald W. Smetana, MD Background: Little is known about the factors related to but this was nonsignificant within studies directly com- the development of pneumothorax following thoracente- paring this factor (OR, 0.7; 95% CI, 0.2-2.3). Pneumotho- sis. We aimed to determine the mean pneumothorax rate rax was more likely following therapeutic thoracentesis (OR, following thoracentesis and to identify risk factors for pneu- 2.6; 95% CI, 1.8-3.8), in conjunction with periprocedural mothorax through a systematic review and meta-analysis. symptoms (OR, 26.6; 95% CI, 2.7-262.5), and in associa- tion with, although nonsignificantly, mechanical ventila- Methods: We reviewed MEDLINE-indexed studies from tion (OR, 4.0; 95% CI, 0.95-16.8). Two or more needle January 1, 1966, through April 1, 2009, and included stud- passes conferred a nonsignificant increased risk of pneu- ies of any design with at least 10 patients that reported mothorax (OR, 2.5; 95% CI, 0.3-20.1). the pneumothorax rate following thoracentesis. Two in- vestigators independently extracted data on the pneu- Conclusions: Iatrogenic pneumothorax is a common mothorax rate, risk factors for pneumothorax, and study complication of thoracentesis and frequently requires methodological quality. chest tube insertion. Real-time ultrasonography use is a modifiable factor that reduces the pneumothorax rate. Results: Twenty-four studies reported pneumothorax rates Performance of thoracentesis for therapeutic purposes and following 6605 thoracenteses. The overall pneumothorax in patients undergoing mechanical ventilation confers a rate was 6.0% (95% confidence interval [CI], 4.6%-7.8%), higher likelihood of pneumothorax. Experienced opera- and 34.1% of pneumothoraces required chest tube tors may have lower pneumothorax rates. Patient safety insertion. Ultrasonography use was associated with sig- may be improved by changes in clinical practice in ac- nificantly lower risk of pneumothorax (odds ratio [OR], cord with these findings. 0.3; 95% CI, 0.2-0.7). Lower pneumothorax rates were observed with experienced operators (3.9% vs 8.5%, P=.04), Arch Intern Med. 2010;170(4):332-339 EDICAL ERRORS HAVE talization. Chest tube insertion may be re- received increasing at- quired in up to 50% of cases, with a mean tention since the pub- duration of placement of approximately lication of the 1999 4 days.4,5 InstituteofMedicinere- According to a 1998 National Center for port ToErrIsHuman:BuildingaSaferHealth Health Statistics study,6 physicians per- M1 System. Among medical errors, procedural form an estimated 173 000 thoracenteses complications are an important source of annually in the United States. Although tho- morbidity. Procedural complications were racentesis generally is considered techni- second in frequency only to medication er- cally straightforward, safe, and well toler- rors among nonoperative adverse events in ated,7 there is wide variation in published the Harvard Medical Practice Study.2 More- pneumothorax rates, ranging from 0%8 to Author Affiliations: Renal over,proceduralcomplicationsconfera17% 19%.9 Researchers have variably investi- Section, Department of Medicine, Boston University gated the role of real-time ultrasonogra- Medical Center (Dr Gordon), CME available online at phy guidance and operator experience as Center for Clinical Evidence www.jamaarchivescme.com modifiable factors that may reduce pneu- Synthesis, Tufts Medical Center and questions on page 315 mothorax rates following thoracentesis. (Dr Balk), and Division of Some uncertainty exists about the magni- General Medicine and Primary excess mortality rate compared with con- tude of the benefit of ultrasonography guid- Care, Beth Israel Deaconess trol subjects matched by the Acute Physi- ance in lowering pneumothorax rates fol- Medical Center, Harvard ology and Chronic Health Evaluation lowing thoracentesis. Investigators have Medical School (Dr Smetana), score.3 Patients who develop procedural attempted to identify patient and proce- Boston, Massachusetts; and Interventional Pulmonology, complications have a 7-day increase in the dural risk factors for the development of Department of Medicine, length of inpatient stay and incur $12 913 pneumothorax following thoracentesis, but 3 The Johns Hopkins Hospital, in excess costs. Iatrogenic pneumothora- results have been inconsistent. Baltimore, Maryland ces resulting from thoracentesis increase To our knowledge, no systematic re- (Dr Feller-Kopman). morbidity, mortality, and length of hospi- view of the pneumothorax rate of thora- (REPRINTED) ARCH INTERN MED/ VOL 170 (NO. 4), FEB 22, 2010 WWW.ARCHINTERNMED.COM 332 ©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/03/2021 [https://research.tufts-nemc.org/ Table 1. Quality Score metaanalyst]). We tested for heteroge- 448 Total records of Included Studiesa neity using the Cochran ␹2 statistic. 41 Duplicate To explore relationships between Quality Factor pneumothorax rates and a priori se- 407 Records screened by title Prospective study design lected procedural and patient charac- and abstract Sequential selection of patients teristics known to be associated with in- Inclusion and exclusion criteria stated creased complication rates following 342 Not relevant or met exclusion explicitly other procedures,11-13 we performed sub- criteria Postprocedural chest radiography group meta-analyses. Patient factors in- performed in 100.0% of subjects 65 Potentially relevant full cluded sex, pleural effusion size, locu- article reviewed Chest radiograph reviewed by independent lation of effusion, and site of procedure clinician (inpatient, outpatient, or intensive care 41 Excluded unit [ICU]). Procedural factors in- a Methodological reasons Each factor receives 1 of 5 potential points. cluded the use of real-time ultrasonog- 11 Pneumothorax not defined 3 Postprocedural chest raphy guidance, level of operator expe- radiography in <95% of patients STUDY SELECTION rience, number of needle passes, and 2 n <10 3 Not specific to thoracentesis whether the procedure was performed for Type of publication Two of us (C.E.G. and D.F.-K.) inde- diagnostic or therapeutic purposes. When 18 Letter to the editor pendently reviewed the 65 retrieved studies reported pneumothorax rates for 2 Summary or review article 1 Position statement studies to determine their eligibility for thoracenteses with and without puta- 1 Abstract our review. Because our focus was on the tive risk factors, we determined the odds development of pneumothorax follow- ratio (OR) of pneumothorax for those risk 24 Reviewed in detail ing thoracentesis, we included only those factors. However, when the study de- studies in which routine chest radiog- sign precluded comparative analysis, we raphy was performed in more than 95% instead calculated summary pneumotho- Figure 1. Results of the literature search. of subjects. We included only articles rax rates across all studies reporting data that (1) provided explicit criteria for the on specific risk factors using random- centesis exists. Our objectives were diagnosis of postprocedural pneumo- effects model meta-analysis (ie, we com- to conduct a systematic review and thorax, (2) clearly stated patient selec- bined all studies that reported pneumo- meta-analysis of the mean pneumo- tion criteria, (3) defined the primary op- thorax rates with ultrasonography thorax rate following thoracentesis erator of the procedure, and (4) enrolled guidance and separately combined all and the procedure- and patient- at least 10 patients. We included pro- studies that reported on unguided tho- related factors associated with the spective and retrospective studies but ex- racentesis). We used a z score to calcu- cluded letters to the editor, editorials, re- late the statistical significance of differ- development of pneumothorax, and view articles, position statements, ences in summary pneumothorax rates to identify modifiable risk factors abstracts, and studies that did not re- between studies with and without spe- that could lead to improved patient port complication rates. Using these cri- cific risk factors (indirect comparisons). safety. teria, we excluded an additional 41 stud- We selected cutoffs to categorize sub- ies (Figure 1). The remaining 24 studies groups after considering the distribution METHODS formed the basis of our review. of our data and after reviewing relevant previous literature. For operator experi- DATA EXTRACTION AND ence, we defined less experienced opera- DATA SOURCES QUALITY ASSESSMENT tors as physicians in residency training AND SEARCHES compared with pulmonary medicine or ra- diology faculty. We considered thoracen- The same 2 of us independently ex- We performed a MEDLINE search of En- tesis to be therapeutic when source stud- tracted available data about complica- glish-language articles from January 1, ies reported that the primary purpose of tion rates and patient and procedural risk 1966, through April 1, 2009. Search the procedure was therapeutic. Typi- factors for pneumothorax. We resolved terms included the Medical Subject cally, this involved drainage of greater vol- any discrepancies by consensus among all Headings terms pneumothorax, ultra- umes of fluid and larger pleural effusions authors. We established an a priori 5-point sound, ultrasonography, complications, than diagnostic thoracentesis,
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