Statistics from Altmetric.com
A 56-year-old woman underwent a bronchoscopy with transbronchial biopsy for work up of interstitial lung disease. The procedure was uneventful and preprocedure and immediately postprocedure lung ultrasound examinations demonstrated no evidence of pneumothorax (video 1). Per hospital protocol, a postprocedure portable chest X-ray (CXR) was obtained but was delayed by 2 hours. The CXR revealed a moderate-sized left pneumothorax (figure 1). A repeat lung ultrasound demonstrated absence of lung sliding and presence of lung point confirming development of pneumothorax (video 1). The pneumothorax was successfully treated with a small-bore tube thoracostomy. The patient was discharged home the next day without further complications.
Pneumothorax complicates approximately 0.63%–0.97% of transbronchial biopsies based on large series conducted in the modern era, but complicates 7.2% of transbronchial biopsies in patients with interstitial lung disease.1–3
In clinical practice, many believe postprocedure pneumothoraces develop quickly (ie, within 1 hour following the procedure), but few studies have reported the time course of post-bronchoscopy pneumothoraces.4 However, many reports of delayed pneumothorax have been described.5–7 No universal definition of delayed pneumothorax exists, but it is often defined as being absent on initial postprocedure imaging but present on subsequent imaging. The time interval to develop a delayed pneumothorax varies between initial and subsequent imaging and ranges from 1 hour to approximately 5 days.4 7 8 Intervals as long as 5 months have been reported; however, in those cases unrelated secondary spontaneous pneumothorax cannot be completely excluded.6 9
Literature on delayed pneumothorax following transbronchial biopsy is limited to case reports.5–7 In contrast, the literature on delayed pneumothorax following transthoracic needle biopsy is more robust. Approximately 20% of transthoracic needle biopsies are complicated by pneumothorax, a rate up to 20 times that of transbronchial biopsy.1 8 Thus, transthoracic needle biopsy cases may serve as a better model to study the timing of iatrogenic pneumothoraces due to the overall increased frequency. In such studies, 15%–18% of pneumothoraces that occurred were considered to be delayed.10 11 Furthermore, delayed pneumothoraces are likely under-reported due to patients being asymptomatic and institutional protocols requiring only an immediate postprocedure imaging study.
Despite being relatively uncommon, a delayed pneumothorax following transbronchial biopsy can evolve into a life-threatening situation, particularly in patients travelling to remote locations, flying by plane soon after bronchoscopy or using non-invasive positive pressure ventilation at home.
CXR has been the standard modality for detecting a postprocedure pneumothorax; however, its role after transbronchial biopsy in asymptomatic patients has been questioned due to its low yield.12 In comparison, clinicians can use bedside lung ultrasound to rapidly rule out pneumothorax by detecting lung sliding, lung pulse or comet tails. A meta-analysis found higher sensitivity (79% vs 40%) and similar specificity (98% vs 99%) of lung ultrasound compared with CXR for detection of pneumothorax.13 For detection of postprocedure pneumothorax, lung ultrasound has been shown to have a sensitivity of 88%–100% and specificity of 97%–100%.14–16
Delayed pneumothorax is an underappreciated complication after transbronchial biopsy that may require tube thoracostomy as demonstrated by this case. Given the clear lung sliding seen on the immediate postprocedure lung ultrasound examination, we believe the pneumothorax was not missed but rather developed in the ensuing hours postprocedure. This case highlights that imaging done immediately after bronchoscopy may not be as sensitive for iatrogenic pneumothorax as imaging done 2 hours postprocedure.
Clinicians should be vigilant for the development of a delayed postprocedure pneumothorax that can manifest a few or several hours after transbronchial biopsy.
Trained clinicians can perform serial lung ultrasound examinations to monitor for development of delayed postprocedure pneumothorax.
Lung ultrasound has superior sensitivity but similar specificity as chest X-ray for detection of pneumothorax.
Contributors SI, KCP, MIV and NS contributed to the conceptualisation of the case report. SI and KCP collected patient data, and KCP, MIV and NS interpreted the data. KCP, NS, SI and MIV drafted the manuscript, made critical revisions and approved the final manuscript. KCP, NS, SI and MIV are accountable for all aspects of the manuscript and KCP is the corresponding author.
Funding NS receives funding from the US Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative Grant (HX002263-01A1). This material is the result of work supported with resources and the use of facilities at the South Texas Veterans Health Care System in San Antonio, Texas.
Disclaimer The contents of this publication do not represent the views of the US Department of Veterans Affairs or the United States Government.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.