Affiliations: Quillen Veterans Affairs Medical Center Mountain Home, TN,
Quillen College of Medicine, East Tennessee State University, Johnson City, TN,
Seoul National University Bundang Hospital Gyeonggi-Do, Korea
Correspondence to: Ryland P. Byrd, Jr, MD, Veterans Affairs Medical Center 111-B, PO Box 4000, Mountain Home, TN 37684-4000; e-mail: Ryland.Byrd@med.va.gov
We read with interest the article by Choi et al1(November 2004) concerning the incidence and risk factors of delayed pneumothorax after transthoracic fine-needle aspiration (FNA) of pulmonary lesions guided by a variety of radiologic techniques. The article is both well written and informative. As the authors indicate in their discussion, it is a common practice to obtain a chest radiograph typically 4 h after percutaneous transthoracic needle aspiration.2
The incidences of early and delayed pneumothorax in the study by Choi et al were 18.6% and 3.3%, respectively. However, all of the patients in their study who required tube thoracostomy for delayed pneumothorax were symptomatic. This represents < 1% of their study population. Interestingly, none of the patients in this study with delayed pneumothorax had undergone CT-guided FNA. We have previously reported that immediate pneumothorax develops in 17.2 to 24.1% of patients undergoing CT-guided FNA.3–4 In our studies, delayed pneumothorax occurs in 2.5 to 3.1% of patients who underwent this procedure. Moreover, delayed pneumothorax requiring intervention with pleural space evacuation occurred in 1.3 to 1.6% of patients.
While we agree the conclusion of Choi et al that late pneumothorax is clinically important, the practice of obtaining a delayed postprocedure chest radiograph after CT-guided FNA does not appear to be an efficient use of resources. Based on our research, chest radiography appears to add little information regarding lung expansion to that obtained by CT at the end of CT-guided FNA. Instruction to seek medical attention in the event of symptoms of pneumothorax appears be a more effective method of addressing this potential complication.
In our study (November 2004),1most transthoracic needle biopsies were performed by fluoroscopic and ultrasonography guidance. Only 4.5% of the transthoracic needle biopsies (21 of 458) were performed with CT scan guidance. Therefore, it is difficult to compare our data to the data of Byrd et al2and Shantaveerappa et al.3
Definitely, CT scanning is more sensitive than a posteroanterior chest radiograph for the detection of pneumothorax. After the analysis of our data, we had a suspicion that a delayed pneumothorax was simply so small and localized that it would go undetected by a posteroanterior chest radiograph at 4 h but would be detectable by CT scan if one were performed.
However, according to his previous work, delayed pneumothorax still occurred in 4 of 158 patients (2.53%) even though a CT scan was performed after the CT scan/fine-needle aspiration.3 This rate is not so different from that in our study1 (3.3%; 15 of 458). The study by Shantaveerappa et al3 helps us to resolve our suspicion. Furthermore, the rate of intervention was even higher (all patients, 1.7% [2 of 158]; patients with delayed pneumothorax, 50% [2 of 4]) in their study3 than that in ours (all patients, 0.65% [3 of 458]; patients with delayed pneumothorax, 20% [3 of 15]).1 I think that the two studies showed quite similar data but different interpretations.
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