iatrogenic lung injuries sins or collateral damage

iatrogenic lung injuries sins or collateral damage

1. ميحرلا نمحرلا الله مسب

2. Iatrogenic lung injuries sins or collateral damage
By
Prof.SamiaaHamdy Sadek
Iatrogenic lung injuries sins or collateral
damage
By
Prof.SamiaaHamdy Sadek

3. Iatrogenic lung injuries
Etiology:
Maneuver induced
Ventilator induced
Drug induced

4. Maneuver induced lung injuries:
Causes:
Pleural biopsy or aspiration
Lung biopsy
Intercostal tube or indwelling catheter
placement
Thoracoscopy
Bronchoscopy
Central catheter placement
Radiofrequency ablation (RFA) of lung
tumors

5. Maneuver induced lung injuries:
Presentation:
Iatrogenic pneumothorax
Subcutaneous emphysema
Hemothorax (intrapleural hemorrhage)
Iatrogenic pleural infection
Drain malposition
Malignant seeding
Pneumonitis duo to talc insufflation during
thoracoscopy.
Iatrogenic air embolism during CVC maneuver.

6. Maneuver induced lung injuries:
How common?
Incidence of iatrogenic pneumothorax was 13%
for CT guided TFNA, 7.1% for pleural biopsy,
16.6%for transbronchial biopsy, 7.1%for
fluoroscopy guided TFNA and 1.5%for
thoracentesis.

7. Maneuver induced lung injuries:
How common:

8. Maneuver induced lung injuries:
How common:
In UK study of 824chest drains inserted for a variety of indications, 3.4% of
patients developed surgical emphysema, pain after the procedure (18%), drains
falling out prematurely (7.3%), drain malposition (2.4%), and drains becoming
blocked (7.4%). Placement of the drain into the lung parenchyma itself has been
reported in up to (10%) of drain insertions
The rate of pleural infection in indwelling pleural catheters in the literature is 2%–
12%.
Rates of bleeding following pleural procedures are low however and range from
0%–2%in the literature but depend on the type of thoracic procedure performed.

9. Ventilator induced iatrogenic lung injuries:
The main injury mechanisms associated with VILI are as
follows:
Barotrauma/volutrauma caused by overstretching the lung tissues,
Atelectrauma, caused by repeated opening and closing of the
alveoli resulting in shear stress,
Biotrauma, the resulting biological response to tissue damage,
which leads to lung and multi-organ failure.
Other mechanisms that are attributed include adverse heart-lung
interactions, deflation related, and effort induced injuries.

10. Drug induced iatrogenic lung injuries:
A wide range of pleural and lung injuries can be
developed secondary to wide variety of drugs.
Clinical and radiological presentations are nonspecific,
so diagnosis sometimes difficult.
High clinical suspicious is the main guide for diagnosis.
In the majority of cases recovery is achieved when the
causative drug is stopped.

11. Examples of drug induced iatrogenic lung injuries:
Some claimed agentsPattern
>350 suspected drugs.
Amiodarone, chemotherapy, statins, methotrexate, nitrofurantoin, TNF-alpha
antagonists, BCG-therapy,, vitamin E acetate
Acute or subacute
ILDs
>80 suspected drugs.
Chemotherapy, amiodarone, nitrofurantoin, bone marrow transplantation.
Do Not Forget: paraquat, radiation to the chest, tobacco smoke.
Pulmonary fibrosis
>200 suspected drugs. Antibiotics (minocycline, azathioprine, betalactam),
amiodarone, anticonvulsant, antidepressants, NSAIDs, chloroquine, leukotriene
receptors antagonists, mesalazine, nitrofurantoin, tryptophan.
Do Not Forget: tobacco smoke.
Eosinophilic
pneumonia
>100 suspected drugs. Amiodarone, antineoplastic including ICIs, statins, rituximab,
sirolimus. Do Not Forget: radiation therapy to the breast.
Organizing
pneumonia
>40 suspected drugs. TNF-alpha antagonists, ICIs, daclizumab, interferon.
Do Not Forget: BCG-therapy (bladder instillation).
Granulomatosis,
Sarcoid-like
granulomatosis

12. Examples of drug induced iatrogenic lung injuries:
Some claimed agentsPattern
>200 suspected drugs. All-trans retinoic acid, aspirin, beta-2-agonists, chemotherapy,
hydrochlorothiazide, IV epoprostenol. Do Not Forget: cocaine, heroin, chlorine gas,
various inhaled chemicals, TRALI, vasodilators in patients with pulmonary
hypertension.
Noncardiogenic
pulmonary
oedema
>150 suspected drugs Amiodarone, anticoagulants, antiplatelet agentsDiffuse alveolar
haemorrhage
>80 suspected drugs. Hydralazine, TNF-alpha antagonists, isoniazid, minocycline,
sulfasalazine, procainamide, beta-blockers, ICIs. Do Not Forget: timolol ocular
drops
Lupus-like
syndrome
>20 suspected drugs. Nitrofurantoin, TNF-alpha antagonists,
propylthiouracil, minocycline, alemtuzumab.
Auto-immune
conditions
including ANCA +
~ 10 suspected drugsCyclophosphamide and other alkylating agents manly
Do Not Forget bone marrow transplantation and lung transplantation
Pleuroparenchym
alfibroelastosis
valproic acid (and its derivatives) and dantrolene tazinidine, trimipramine and fluoxetine
nitrofurantoin, daptomycin and tosufloxacin
Eosinophilic
pleural effusion

13. How to avoid???

14. Minimizing risk of pleural injuries during
different maneuvers:
Guidelines now recommend the routine use of thoracic ultrasound guidance for
most pleural and pulmonary procedures.
In one study comparing ultrasound to physical exam in selecting the
appropriate puncture site, ultrasound prevented organ puncture in 10% of
overall cases and increased the accuracy of the puncture site by 26%.
Understanding underlying thoracic anatomy is critical in minimizing risk of
complication.
The major relevant structures include the chest wall, ribs, intercostal
neurovascular bundle (consisting of an intercostal vein, artery, and nerve),
heart, lungs, diaphragm, and subdiaphragmatic organs

15. Minimizing risk of pleural injuries during
different maneuvers:
The intercostal neurovascular bundle tracks along the
inferior margin of the associated rib and injury to this
bundle can increase the risk of bleeding and pain.
Access to the pleural space is typically approached
over the superior rib margin.
It should be noted that this vessel to-rib relationship is
less reliable along the posterior and medial aspect of
the ribs particularly in elderly
A lateral approach is generally preferred to lessen risk
of injury
A digitally enhanced CT reconstruction highlighting the
tortuous course of an ICA in an elderly man (red lines)

16. Minimizing risk of pleural injuries during
different maneuvers:
Proper patient positioning is also an important
aspect of many pleural procedures
The ‘triangle of safety,’ which is the preferred
area of entry when not using ultrasound
localization.
The ‘triangle of safety’ is bordered by the
superior aspect of the fifth rib inferiorly, the
lateral edge of latissimus dorsi posteriorly, and
the lateral edge of pectoralis major anteriorly.
Triangle of safety. Original image by Henry Vandyke
Carter/Public Domain and modified by the authors.

17. Minimizing risk of pleural injuries during
different maneuvers:
The triangle of safety is appropriately
exposed when the patient is:
Lying in the lateral decubitus position,
Sitting upright and leaning forward with
arms raised, and
Lying in the semi-recumbent position with
the arm raised above the head.
Notably, the left oblique fissure (small dashed line) passes
through the triangle of safety, which leads to the risk of chest tube
placement within the fissure. Original image by Henry Vandyke
Carter/Public Domain and modified by the authors.

18. Minimizing risk of pleural injuries during
different maneuvers:
In order to minimize drain malposition, pleural
ultrasound is recommended to guide all pleural
procedures
In some scenarios where the anatomy is difficult to
delineate even with ultrasound, CT may be required to
guide the drain insertion

19. Minimizing risk of pleural injuries during
different maneuvers:
There is debate about the amount of pleural fluid
aspirated during therapeutic thoracentesis, but in general
with the onset of symptoms such as cough, pain and
difficulty breathing, thoracentesis should be stopped.
In addition, fluid aspiration should be stopped in cases in
which it becomes difficult, as this indicates changes in
pressure within the pleural cavity that may lead to the
development of post expansion pulmonary oedema.

20. Minimizing risk of pleural injuries during
different maneuvers:
The first step in prevention of intrapleural hemorrhage is the
avoidance of elective procedures while patients are receiving
therapeutic anticoagulation or have Any coagulopathy or
platelet deficiency
Aspirin is believed to be safe during pleural procedures
If urgent procedures, or if anticoagulation cannot be stopped,
the risk-benefit ratio needs to be assessed and discussed
with the patient.

21. Minimizing risk of pleural injuries during
different maneuvers:
Empirical antibiotics have been shown to be beneficial in
reducing the incidence of pleural infection when a chest drain
is inserted for trauma.
Indwelling pleural catheters are increasingly used in the
management of malignant pleural disease Strict asepsis at
the time of drain placement, along with careful patient
education regarding drain care, may help to reduce the risk of
infection.

22. Minimizing risk of pleural injuries during
different maneuvers:
Procedure tract metastases (PTM) , invasive pleural procedures
including indwelling pleural catheters, may cause seeding of
tumor cells along the tract created during the intervention.
The larger the incision made in the chest wall, the higher the
chance of tract metastases developing.
Review of the literature found the mean time to development of
PTM was 6.5 months (range 4.5–9 months)

23. Minimizing risk of pleural injuries during
different maneuvers:
Prophylactic radiotherapy may be given to patients with
mesothelioma who undergo invasive pleural procedures to try
and prevent this occurring, but the result of the studies is
conflicting.

24. Minimizing bronchoscopy
complications:
The 2 major complications of bronchoscopy
are hemorrhage and pneumothorax.
A platelet count of at least 20,000 per mm3
for performing BAL, andat least 50,000 per
mm3 for performing EBB/TBLB is
recommended.
In patients with thrombocytopenia, oral
route is preferred for performing
bronchoscopy.
Clopidogrel, prasugrel, or ticagrelor should
be discontinued at least 5 days before EBB
and TBLB •
Low-dose aspirin can be continued in
patients planned for TBLB/EBB.

25. Minimizing bronchoscopy complications:
Warfarin should be stopped at least 5 days prior to transbronchial needle
aspiration (TBNA) or bronchoscopicbiopsy and a preprocedureINR of <1.5
should be ensured.
Newer anticoagulants should be stopped at least 2 days before TBNA or
bronchoscopicbiopsy .
Bridging therapy with LMWH in patients on anticoagulation and at high risk of
thrombosis is recommended.
LMWH, when indicated, should be started 2 days after stopping warfarin. The last
dose of LMWH should be administered 24 h before the procedure.

26. Minimizing bronchoscopy complications:
For bronchoscopy through the nares, phenylephrine 0.5% or xylometazoline 0.1%
can be helpful in vasoconstricting the mucosa of the nares and allowing easier
passage of the scope.
Cough suppression and adequate sedation are important to reduce the risk of
pneumothorax arising from cough -induced barotrauma.
If procedures, such as BAL, endobronchial biopsy, transbronchial needle
aspiration (TBNA) are required, BLB should be carried out last.
If available fluoroscopy should be used routinely.

27. Minimizing bronchoscopy complications:
After ascertaining the appropriate site for biopsy, the bronchoscope is advanced
and wedged in the bronchial subsegment, while the forceps is advanced to the
target under fluoroscopic guidance.
The forceps is opened 5–6 mm proximal to target, advanced and closed. The
patient is then asked if pain is experienced before the forceps is withdrawn.
If there is pain or if the pleura is pulled back during retraction of forceps, the
forceps are open, withdrawn proximally and another area is attempted.

28. Minimizing bronchoscopy complications:
For TBLBs the most commonly recommended techniques are:
1)to wedge the bronchoscope into the target airway during and after the biopsy
until haemostasias is achieved, avoiding suctioning in order to allow clot
stabilization, or
2) without wedging the bronchoscope, suction with the “back-and-forth technique”
in the case of bleeding until bleeding stops.

29. Thoracoscopic complications:
After the procedureDuring the procedureBefore the procedure
Re-expansion pulmonary oedema
Pain
Postoperative fever
Wound infection
Hypotension
Empyema
Subcutaneous emphysema
Persisting pneumothorax
Prolonged air leakage
Continuing pleural fluid
production
Early and late complications after
talc pleurodesis
Seeding of chest wall by tumour
cells
Mortality
Pain
Hypoxaemia
Hypoventilation
Cardiac arrhythmias
Hypotension
Haemorrhage
Injury to lung or other organs
Air embolism,
subcutaneous
emphysema and pain
during pneumothorax
induction
Shortness of breath after
pneumothorax induction
Hypersensitivity reaction
to local anaesthetic

30. Minimizing thoracoscopic complications:
Postpone for several days if severe cough is present;
Measure blood gases; monitor cardiac status; and oxygenate the patient during the
procedure.
Coagulate and ensure haemostasias
Insert a chest tube until no air leakage is detected to prevent subcutaneous
emphysema and start a lung expansion protocol on the day after medical
thoracoscopy/pleuroscopyto prevent atelectasis.
Start gentle suction to avoid re-expansion pulmonary oedema.
To prevent invasion of the insertion track of the thoracoscope in malignant
mesothelioma, consider radiation therapy of 7 Grays per day for 3 days to the
incision area.

31. Management of some iatrogenic lung
injuries

32. Iatrogenic pneumothorax:
Mechanisms:
Direct injury to the visceral pleura via laceration or
puncture.
The entrainment of outside air into the pleural space via
the needle, catheter, or incision site.
Pneumothorax ex vacuo can occur when fluid is removed in
the setting of non-expandable lung, leaving a negative
pressure space.

33. Iatrogenic pneumothorax:
Guidelines recommend the following regarding postprocedural
pneumothorax:
(I)If the pneumothorax is small (<2 cm) between the chest wall
and lung at the apex) and the patient is asymptomatic
observation and supplemental oxygen are all that is needed.
(II)If the patient is symptomatic, the pneumothorax is large (>2
cm between chest wall and lung at the apex), or if the
pneumothorax is expanding , tube thoracostomy is indicated

34. Iatrogenic intrapleural bleeding:
Mechanisms:
Bleeding may be arterial or venous and is often related to
damage to the intercostal vessels.
Bleeding is suspected in the post-procedure setting with
the rapidly reaccumulating pleural fluid, which can be
visualized sonographicallyor radiographically.
Rapid onset of respiratory symptoms such as shortness of
breath or chest pain.

35. Iatrogenic intrapleural bleeding:
Post-procedural bleeding is superficial and can be managed with
external pressure, use of thrombostaticmaterial, biological sealant,
electrocoagulation, and placement of a chest tube for hemothorax.
In case of massive bleeding the first goal is simultaneous resuscitation
with blood product transfusion being the ideal fluid in hemodynamic
instability.
Surgical intervention typically includes urgent consultation to thoracic
surgery for consideration of thoracotomy and to interventional
radiology for consideration of transcatheter arterial embolization.

36. Iatrogenic intrapleural infection:
For the diagnosis of iatrogenic pleural infection fluid and blood should be sent
for culture to help identify a causative organism and identify antibiotic
resistance.
Fluid drainage, antibiotics, and careful attention to nutrition are key
components of management.
Antibiotics should be broad spectrum and have good cover for hospital -
acquired organisms, such as the gram negatives and methicillin -resistant
Staphylococcus aureus (MRSA).
If a chest drain becomes secondarily infected, it may be necessary to remove
the infected drain and re-site a new one. Some patients may require surgical
intervention if medical management fails.

37. Iatrogenic
bleeding during
bronchoscopy:
Proposed plan of action in
the case of iatrogenic
bleeding during flexible
bronchoscopy originating
from the periphery.

38. Iatrogenic bleeding during bronchoscopy:
Turning the patient onto the bleeding side and in an anti -Trendelenburg
position should be the first reaction in order to prevent and minimise
inundation of the non-bleeding lung and guarantee adequate oxygenation.
Wedging of the bronchoscope limits bleeding to subsegment of the lung and
confers a ‘tamponade’ effect.
If significant bleeding is encountered (>50 mL) the wedge position is
maintained, 10–15 mL of iced saline is instilled through the bronchoscope, and
allowed to flood the lung subsegment before suction is resumed.
The addition of 1 mL epinephrine (1 : 1000) to the aliquot of ice saline aids in
controlling hemorrhage from distal areas.

39. Iatrogenic bleeding during bronchoscopy:
Other haemostaticagents can be tried if available e.g. The
antidiuretic hormone (ADH or vasopressin) analogues, IV or
intrabronchial terlipressin(also called glypressin),
Tranexamic acid (TXA) and ornipressin,
Bleeding usually stops with these manoeuvres in most
patients, however, if persistent, balloon tamponade, fibrin
glue application, isolation of bronchial tree with double
lumen endotracheal tubes, and surgical resection of the
bleeding segment are considerations.

40. Iatrogenic bleeding during bronchoscopy:
Bleeding from a central lesion:
In case of visible central source of bleeding, the opportunity for targeted coagulation
should be considered. Argon plasma coagulation (APC) is a noncontact thermal
ablation technique that uses argon gas to generate heat, which, in turn, can be used to
achieve haemostasis.
Thermal energy is delivered with a depth of penetration of roughly 2–3 mm, producing
tissue coagulation and destruction. Due to these features, APC is a useful modality for
the treatment of superficial/flat lesions, as well as those that are highly vascular or
bleeding.
Its advantages include its ease of application and safety due to its reduced depth of
penetration and lower cost compared to laser techniques. The plasma jet also
improves visualisationof the bleeding lesion due to the clearing effect of the gas jet.

41. Iatrogenic bleeding during bronchoscopy:
Bleeding from a central lesion:
Laser coagulation therapies (mostly Nd:YAPor diode lasers)
are other valuable possibilities that allow deeper
coagulation. However, laser coagulation should be
performed by an experienced interventional bronchoscopist
due to the deeper penetration and risk of complications.
Furthermore, monopolar electrocautery can be used for
contact diathermy coagulation.

42. Take home message:
Iatrogenic lung injuries are collateral damage but also
avoidable complications.
Carful pre-procedure clinical, laboratory, radiological,
and functional assessment is mandatory in reducing
risk of injuries.
Transthoracic ultrasound is the cornerstone in
evaluating patients prior to any invasive maneuver.

43. Take home message:
Meticulous post-procedure supervision is critical in
early detection of complications.
Finally every medical intervention is double-edged
sword,one of which is encouraging and the other is
frustrating. Do your best to provide the patient
encouraging one.