Delayed tension pneumothorax complicating central venous catheterization and positive pressure ventilation

Pneumothorax is the most common complication after central venous catheterization. The diagnosis of pneumothorax may be delayed for hours or days, in some instances because of minimal clinical symptoms or radiographic signs on initial evaluation, or in other instances because of late presentation precipitated by positive pressure ventilation. A case is presented in which a patient developed a tension pneumothorax while under general anesthesia 10 days after central venous line placement. A review of the literature suggests that delayed pneumothorax has an incidence of approximately 0.4% of all central venous access attempts, is much more common after subclavian than internal jugular approaches, especially in difficult or multiple attempts, is asymptomatic in 22%, and results in tension pneumothorax in 22%. End-expiratory upright chest radiographs, the optimal radiographic technique for detection of small pneumothoraces, were obtained in only 19% of reviewed cases. Supine views, the least sensitive radiographic technique, should be carefully reviewed for evidence of basilar hyperlucency, a deep sulcus sign, or a double diaphragm sign. In patients unable to tolerate the upright position, supine views should be supplemented with lateral decubitus, oblique, or cross-table lateral views. Emergency physicians should be aware of the possibility of delayed pneumothorax, as well as optimal radiographic technique for demonstration of small pneumothoraces, and subtle radiographic findings in supine or semirecumbent patients.