Elsevier

Heart & Lung

Volume 44, Issue 3, May–June 2015, Pages 238-242
Heart & Lung

Care of Children With Cardiac and Pulmonary Conditions
Iatrogenic pneumothorax in mechanically ventilated children: Incidence, risk factors and other outcomes

https://doi.org/10.1016/j.hrtlng.2015.01.005Get rights and content

Abstract

Objectives

Determine prevalence, risk factors and outcomes of iatrogenic pneumothoraces (IPs) in a pediatric intensive care unit (PICU).

Methods

Patients with IP (cases) and patients without IP (controls) were retrieved from a 5-year prospective cohort of 645 PICU patients who received mechanical ventilation (MV).

Results

Twenty cases and eighty controls were assessed. The overall prevalence of IP was 3%. Eleven IPs were procedure-related IP and 9 MV related. Performance of thoracic invasive procedures (odds ratio 11) was the significant IP predictor in the logistic regression analysis. IP incidence was higher within 12 hours. There were no differences between the groups concerning duration of MV, length of PICU and hospital stays. IP patients had a significantly higher mortality rate (p = 0.005).

Conclusions

Performance of thoracic invasive procedures was strongly associated with IPs events in mechanically ventilated children. Many of these events may potentially be preventable with the implementation of quality improvement programs.

Introduction

Iatrogenic pneumothorax (IP) is a potentially life-threatening event as well as one of the main iatrogenic complications in intensive care unit (ICU) patients.1, 2 This event occurs predominantly as a complication of barotrauma related to mechanical ventilation or as a post-procedural event (e.g., after central venous catheter insertion, thoracentesis, or surgery) and, it has been associated to increases in ICU length of stay, resource use, and mortality.1, 3, 4, 5 Nevertheless, there are only a few studies in adult population describing the outcome and prognostic factors associated with iatrogenic pneumothorax in ICU patients1, 4, 5 and the available pediatric studies are limited to merely report the overall incidence of IP in children.3, 6, 7, 8 In addition, most studies of IP in adults were retrospective cohort and focused on a single category of IP.1 Of note, there is a lack of pediatric studies addressing IP in a case-controlled approach or assessing its incidence and circumstances, or the outcomes after IP on mechanically ventilated children.

The aim of this study was to identify the prevalence and risk factors associated with the IP in critically ill children receiving mechanical ventilation. Secondarily, we assessed the outcome of this event. We hypothesized that a high number of IP in PICU patients may be preventable, thus, identifying modifiable risk factors for complications is especially important to take preventive actions to minimize the incidence of these events.

Section snippets

Study design

This was a matched case–control study comprising a five years period (from January 2009 through December 2013). This study was performed in an eight-bed PICU within a tertiary university–affiliated hospital. The Institutional Review Board approved the study and waived the need of informed consent.

Although we had no formal mechanical ventilation protocol for patients with Acute Lung Injury (ALI)/Acute Respiratory Distress Syndrome (ARDS), it is our institutional practice to use pressure-limited

Results

During the study, there were 1515 PICU admissions. Of these, a total of 645 (42.5%) patients were mechanically ventilated (7951 ventilator days). Among these, 20 patients had pneumothorax while receiving mechanical ventilation (3% incidence rate). Invasive thoracic procedures were the most frequent IP cause affecting 11 (55%) patients. IP-CVC occurred in 9 patients, whereas IP-thoracentesis occurred in 2 patients, with a median time from VM to IP of 4.5 days, with a median time from MV

Discussion

As IP is a rare event,1 we designed a case–control study since it is widely used to study rare diseases, usually requiring few cases.14 Besides, in light of the impossibility of performing a randomized prospective study for IPs this design affords the best evidence-based medicine approach.14

Hence, assessing a high-risk population for developing IP during the PICU stay as a case–control study makes this study unique. Firstly, we found that the prevalence of IPs for mechanically ventilated

References (28)

  • A. de Lassence et al.

    Pneumothorax in the intensive care unit: incidence, risk factors, and outcome

    Anesthesiology

    (2006)
  • C.W. Hsu et al.

    Clinical characteristics, hospital outcome and prognostic factors of patients with ventilator-related pneumothorax

    Minerva Anestesiol

    (2014)
  • M.R. Miller et al.

    Pediatric patient safety in hospitals: a national picture in 2000

    Pediatrics

    (2004)
  • K.Y. Chen et al.

    Pneumothorax in the ICU: patient outcomes and prognostic factors

    Chest

    (2002)
  • B. Celik et al.

    Iatrogenic pneumothorax: etiology, incidence and risk factors

    Thorac Cardiovasc Surg

    (2009)
  • B. Friedman et al.

    Annual report on health care for children and youth in the United States: focus on trends in hospital use and quality

    Acad Pediatr

    (2011)
  • A. Sedman et al.

    Relevance of the Agency for Healthcare Research and Quality Patient Safety Indicators for children's hospitals

    Pediatrics

    (2005)
  • M.C. Scanlon et al.

    Evaluation of the agency for healthcare research and quality pediatric quality indicators

    Pediatrics

    (2008)
  • J.H. Kao et al.

    Impact and predictors of prolonged chest tube duration in mechanically ventilated patients with acquired pneumothorax

    Respir Care

    (2013)
  • M.M. Pollack et al.

    Pediatric risk of mortality (PRISM) score

    Crit Care Med

    (1988)
  • S. Leteurtre et al.

    Validation of the paediatric logistic organ dysfunction (PELOD) score: prospective, observational, multicentre study

    Lancet

    (2003)
  • C.G. Mayhall

    Ventilator-associated pneumonia or not? Contemporary diagnosis

    Emerg Infect Dis

    (2001)
  • J.H. van der Lee et al.

    Efficient ways exist to obtain the optimal sample size in clinical trials in rare diseases

    J Clin Epidemiol

    (2008)
  • B. Nan et al.

    Analysis of case-control age-at-onset data using a modified case-cohort method

    Biom J

    (2008)

    • Author contribution: PSL da Silva – conception and design, analysis and interpretation of data, drafting of the manuscript, revision and final approval of the manuscript submitted. VE Aguiar – analysis and interpretation of data, drafting of the manuscript, revision and final approval of the manuscript submitted. MCM Fonseca – conception and design, analysis and interpretation of data, drafting of the manuscript, revision and final approval of the manuscript submitted.

    Conflict of interest: The authors report no conflicts of interest.

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