Presentations

Abstract

Introduction:

Iatrogenic pneumothorax is a usually benign complication most commonly caused by transthoracic needle aspiration, central venous catheterization, and thoracentesis, amongst other standard hospital procedures, with an incidence of 1.36% by some estimates. Here we describe a rare case of iatrogenic pneumothorax involving a dry-needling (DN) procedure.

Case Information:

A 66-year-old female with a medical history of hypothyroidism, chronic myalgias, and obstructive sleep apnea on CPAP presented to the emergency department with pleuritic chest pain, dyspnea, and left neck pain for two days after undergoing posterior cervical dry needling by her chiropractor for chronic pain management Initial vital signs were stable with SpO2 98% and an unremarkable physical exam. Chest X-ray (CXR) revealed a 3.5 cm left apical pneumothorax. She was treated with 100 % supplemental oxygen via nonrebreather, and repeat imaging demonstrated a reduction to 2.6 cm after four hours. The patient's pain improved significantly over 24 hours, and serial imaging showed less than 2 cm of residual pneumothorax. She was discharged in stable condition from the hospital and asked to hold off on using her CPAP till she received clearance from pulmonology. CXR on follow-up ten days later showed near complete resolution of the pneumothorax, and pulmonology cleared her to use her CPAP machine the following week.

Discussion/Clinical Findings:

According to a survey in 2008, approximately 38% of Americans utilize alternative medical therapy. DN is a common complementary treatment offered in some physical therapy and chiropractic practices. DN is an alternative medicinal procedure involving filiform or hypodermic needles inserted into trigger points to treat musculoskeletal pain. The modality is similar to acupuncture but usually involves deeper needle insertion. Although research on the efficacy of this modality is limited, dry needling has been effective in clinical trials for the treatment of myofascial pain. Unfortunately, there is no standardized regimen, and there is a current gray zone in the practice of DN versus acupuncture.

Acupuncturists are licensed and undergo training, certification, and continuing education. Unfortunately, the training and accreditation for dry needling are not as rigorous as for acupuncturists. The American Medical Association adopted the following policy on June 15, 2016, stating that dry needling must be regulated with the same standards as acupuncture, stating that "...physical therapists and other non-physicians practicing dry needling should - at a minimum - have standards that are similar to the ones for training, certification and continuing education that exist for acupuncture.

The optimal management of iatrogenic pneumothorax is unstudied. Patients with iatrogenic pneumothorax are generally treated as if they had a primary spontaneous pneumothorax. Small Pneumothorax (less than or equal to 3 cm from apex or l2 cm from hilum) can be managed with oxygen, observation, and repeat imaging. Our patient did well despite having a large pneumothorax and not receiving drainage via a needle or catheter.

Conclusion:

The potential risks and benefits of alternative therapies such as DN should be discussed with patients, and shared decision- making can help reduce the chances of adverse events. This case brings to the forefront the risks of alternative therapies.