title: Pneumothorax is a rare complication of thoracic central venous catheterization in community EDs.
abstract: OBJECTIVE
  The rate of iatrogenic pneumothorax associated with thoracic central venous catheterization in community emergency departments (EDs) is poorly described, although such information is vital to inform the procedure's risk/benefit analysis. We undertook this multicenter study to estimate the incidence of immediate catheter-related pneumothorax in community EDs and to determine associations with site of access, failed access, and positive pressure ventilation.
  
  
  METHODS
  This was a secondary analysis of 2 retrospective cohort studies of adults who underwent attempted thoracic central venous catheterization in 1 of 21 EDs. Pneumothorax was identified by postprocedural anteroposterior chest radiograph or emergent evacuation for presumed tension pneumothorax. Frequencies were compared using Fisher's exact test.
  
  
  RESULTS
  Among 1249 patient encounters, the initial vein of catheterization was internal jugular in 1054 cases (84.4%) and subclavian in 195 cases (15.6%). Success at the initial internal jugular vein was more common than at the initial subclavian vein (95.4% vs 83.6%, P < .001). Periprocedural positive pressure ventilation was administered in 316 patients (25.3%). We identified 6 pneumothoraces (0.5%; 95% confidence interval, 0.2%-1.1%). The incidence of pneumothorax was higher with the subclavian vein than the internal jugular vein (2.3% vs 0.1%, P < .001), with failed access at the initial vein (2.5% vs 0.3%, P = .05), and among patients receiving positive pressure ventilation (1.6% vs 0.1%, P < .01).
  
  
  CONCLUSIONS
  The incidence of pneumothorax from thoracic central venous catheterization in community EDs is low. The risk of pneumothorax is higher with a subclavian vein approach, failed access at the initial vein, and positive pressure ventilation.
authors.affiliation: The Permanente Medical Group, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA. Electronic address: drvinson@ucdavis.edu.
authors.forename: David R
authors.initials: DR
authors.lastname: Vinson
authors.affiliation: The Permanente Medical Group, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, CA.
authors.forename: Dustin W
authors.initials: DW
authors.lastname: Ballard
authors.forename: Luke G
authors.initials: LG
authors.lastname: Hance
authors.affiliation: Loma Linda University School of Medicine, Loma Linda, CA.
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Stevenson
authors.affiliation: The Permanente Medical Group, Oakland, CA; Department of Radiology, Kaiser Permanente San Rafael Medical Center, San Rafael, CA.
authors.forename: Victoria A
authors.initials: VA
authors.lastname: Clague
authors.affiliation: Kaiser Permanente Division of Research, Oakland, CA.
authors.forename: Adina S
authors.initials: AS
authors.lastname: Rauchwerger
authors.affiliation: Kaiser Permanente Division of Research, Oakland, CA.
authors.forename: Mary E
authors.initials: ME
authors.lastname: Reed
authors.affiliation: The Permanente Medical Group, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA.
authors.forename: Dustin G
authors.initials: DG
authors.lastname: Mark
mesh_terms: D000368:Aged; D002405:Catheterization, Central Venous / Q000009:adverse effects*; D004636:Emergency Service, Hospital; D006764:Hospitals, Community; D006801:Humans; D011030:Pneumothorax / Q000209:etiology*; D012307:Risk Factors; D013909:Thorax / Q000098:blood supply*