The management of a spontaneous left pneumothorax

A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for the management of a spontaneous left pneumothorax (collapse of her lung). She required urgent thoracostomy (chest tube) placement in the emergency department.

The chest tube was connected to wall suction in order to promote the re-expansion of her lung.

Over the next 2 days, the patient improved, and repeat imaging showed a re-expansion of her lung.

The consulting pulmonary team felt that the chest tube might be able to be removed, so they requested that the tube be disconnected from suction and clamped.

The plan was to obtain a chest radiograph 1 hour after clamping the tube, and if the pneumothorax had not recurred, the tube would be removed.

About 45 minutes after the tube was clamped, the patient complained of acute, sharp pain radiating to her left arm. The nurse gave the patient pain medication.

She noted that the radiograph had not yet been done but assumed that it would be done soon. Unfortunately, the radiograph was not done, and the nurse became busy with another acutely deteriorating patient.

Approximately 2 hours later (3 hours after the tube was clamped), the nurse found the patient unresponsive, in cardiac arrest with a rhythm of pulseless electrical activity.

A code blue was called. The code team recognized that the arrest could have been due to a tension pneumothorax, reconnected the chest tube to suction, and eventually performed needle decompression.

Despite these measures, the patient did not recover spontaneous circulation for more than 30 minutes and sustained a severe anoxic brain injury as a result.

The patient required tracheostomy and feeding tube placement, and she was eventually transferred to a long-term care facility with a poor neurologic prognosis.

The hospital conducted a root cause analysis (RCA). The RCA committee found that there was considerable variation around chest tube removal practices between services. For example, the trauma surgery service did not routinely perform a clamping trial before chest tube removal.

Although other services did perform such a trial, there was variation in when the radiograph was performed after clamping the tube.

The committee noted that this variation led to confusion among bedside nurses about how to monitor patients and communicate with physicians immediately after chest tube removal.

As a result, the committee felt the complication might still have occurred even if the radiograph had been performed.