Abstract Introduction Pneumothorax (PTX) is a common problem across emergency departments in the United States, with an estimated 20,000-40,000 cases occurring annually. We present a case of small-bore tube thoracostomy, which was complicated by insertion into the trachea - the first report of such in the literature. Case Presentation A 22-year-old male presented with sudden onset chest pain and dyspnea three weeks following a gunshot wound to the chest requiring a right thoracotomy for tractotomy and right middle lobe wedge resection. After visualization of a large, right-sided pneumothorax without tension physiology on chest radiograph, a small-bore chest tube was placed under ultrasound guidance. Upon insertion, a continuous air leak was noted in the atrium. A computed tomogram (CT) of the chest demonstrated intraparenchymal placement through a post-operative consolidation before entering the bronchus intermedius and terminating within the trachea. This tube was replaced by a surgical chest tube, but a persistent air leak remained, concerning for bronchopleural fistula. An apical chest tube was placed with resolution of the PTX. The patient was transferred to another center for thoracic surgery evaluation, where bronchoscopy demonstrated no large airway injury. Ultimately, his PTX resolved with conservative management, and chest tubes were removed before discharge without reaccumulation. Discussion Tube thoracostomy is a procedure in which a flexible tube is inserted into the pleural space within the chest to remove accumulated air or fluid. PTX may undergo thoracostomy if it is recurrent, persistent, traumatic, large, under tension, or bilateral. Common complications include tube blockage, dislodgement, bleeding, infection, intercostal neuralgia, and malpositioning. Malposition of the tube most often occurs intraparenchymally, subdiaphragmatically, within the lobar fissure, or subcutaneously. Intraparenchymal tube malposition means that the underlying pleural problem is not addressed, but may also lead to bronchopleural fistula development, possibly necessitating additional invasive interventions. Typically, the first step in management of malposition of the tube is removal and replacement with a well-positioned chest tube for ongoing drainage. Often, the “triangle of safety” is used as a guide for chest tube placement, but it does not always account for anatomic variability in patients who have had chest trauma, including prior surgery. Conclusion This is the first documented case of iatrogenic bronchopleural fistula with termination of the small-bore catheter within the trachea. Bronchopleural fistulas are a challenging clinical scenario to navigate, with outcomes depending on each individual’s etiology, anatomy, and comorbid conditions. Individualized treatment planning is recommended. This abstract is funded by: None
Savage et al. (Fri,) studied this question.