An inappropriate therapeutic intervention can delay completion of treatment: Caution required!

The appropriate treatment of any pathology is connected with the possibility of making a rapid and correct diagnosis. Sometimes, on one hand, the pathology is not definable in advance in its course, and on the other hand, the clinical signs are unclear and the initial empirical treatment applied is neither satisfactory nor does it resolve the symptoms that the patient presents. The delay in diagnosis and consequently the application of adequate therapy can influence the course of the patient and the evolution of the disease up to affecting the outcome.

Diagnosis can be delayed, especially when the clinical signs are not very clear or when the response to a treatment applied is neither satisfactory nor does it resolve the pathology.[1] The pathology for which the patient is affected may have complications directly related to the pathology itself (i.e., rupture of the pulmonary bulla and creation of the pneumothorax), or the complication may have an iatrogenic etiology linked to the undesirable effects of the applied treatments. Failure to recognize that the complication is linked to the iatrogenic treatments applied can lead to a wrong diagnosis by attributing the undesirable effects of the treatment to the known evolution of the underlying pathology.

In many cases, for diagnostic and/or therapeutic needs, invasive maneuvers are carried out during treatment with the aim to favor the resolution of the pathology. For example, the drainage of empyema is frequently performed to resolve the pathology, but if the drain tube is placed blindly, it may get exposed to the risk of inappropriate placement causing serious complications. Like any surgical procedure, drain tube placement (i.e., in pleural empyema) can cause bleeding, pneumothorax, and infection.[2]

Bronchopleural fistula (BPF) – which can also be caused by incorrect positioning of the chest drain – causes loss of effective tidal volume, aspiration of infected pleural fluid, respiratory distress, and prolonged ventilatory support.[3]

The injury created by incorrect placement of a drain can be highlighted by radiological investigation only if the drain tube is in situ. Otherwise, if the drain tube has been removed, it will be difficult to demonstrate a causal relationship, that is, between lung rupture and the drain tube placement. In any case, the doubt or suspicion that this has happened must be raised.

Interventions at iatrogenic risk must be adequately planned, prepared, and performed in order to avoid possible immediate and distant complications. For this purpose, the operation must be performed by specialists with adequate experience for the specific manoeuver. Many complications can arise due to the unfavorable result of a disease, health condition, or treatment and also from medical errors or due to actions or omissions caused by negligence, imprudence, and inexperience. Although all harms resulting from negligence are iatrogenic, not all iatrogenic injuries are negligent.[4]

In order to avoid diagnostic and therapeutic errors, each invasive intra-cavitary maneuver should be performed under direct visual control (i.e., under ultrasound, computed tomography, or fluoroscopy). Choosing a specific imaging modality can help to determine the technique to use, control the correct execution of the maneuver, and highlight the result obtained and any complications that may have arisen. The accurate execution of the therapeutic maneuver allows the reduction of the side effects of the treatments.[5]

If a complication is suspected or occurs during the execution of an invasive manoeuver, what happened must be carefully studied and the side effects must be documented. Accidental puncture or laceration is a quality measure as patient safety indicator (PSI), which reports the rate of inadvertent cuts, punctures, perforations, and lacerations that are caused during the procedure.[6]

Having confirmation through evidence of what happened and the damage realized allows to obtain the correct diagnosis and apply the appropriate treatment in the shortest time. A complication that is not promptly highlighted and not treated immediately can remain undetected for a long time, does not favor healing (e.g., fistula not repaired and need for thoracoscopic surgery), and extends the hospital length of stay and treatment costs. These complications can be a contributing factor that triggers litigations.

In this issue of the journal, the study by Kodaka et al.[7] should be commended for reporting a complication of Lemierre syndrome, not previously reported in the literature, because this adds to the literature on treatment of this serious disease and its complications. Furthermore, Kodaka et al.[7] offer an opportunity to revisit the treatment approach to a potentially serious complication of BPF.[8]

Without detracting from the case reported by Kodaka et al.[7] and accepting its validity, uncertainty remains about the origin of the fistula that is difficult to clarify based solely on the evidence presented by the authors. Can the causes be traced to a spontaneous pneumothorax and therefore the formation of fistula or to a pulmonary rupture and consequent fistula following iatrogenic application of a chest drain in a non-compromised or compromised lung area?

While treating a complication it must be ensured that new complications, which could sometimes be even more serious than the initial pathology, do not arise. Videothoracoscopy may be required when insertion of a chest tube does not resolve the empyema or for any complications that have occurred due to its incorrect positioning, that is, thickening of the pleura and incomplete expansion of the lung. Videothoracoscopic surgery will enusre the complete cleaning of the pleural cavity, the removal of the adhesive pleurisy (decortication), and the re-expansion of the lung.

In the presence of a BPF, endopleural lavage (while the patient is breathing spontaneously) is contraindicated because during the inspiratory phase, the lavage fluid can migrate and spread from the infected lung to the contra-lateral relatively healthy lung. The diffusion of infected material to both lungs can cause a severe massive aspiration syndrome, which can evolve into acute respiratory distress syndrome (ARDS). A protective maneuver to control the spread of infected material to both lungs can be achieved by selective intubation of the two lungs with a double lumen tube that protects the contra-lateral lung from the spread of infectious material present in the affected lung.[9]

It is important to remember that any invasive maneuver can have side effects that can delay resolution of the underlying pathology. Radiological investigations and ultrasound can, on one hand, avoid damage from incorrect maneuvers and, on the other, confirm the correct positioning of the applied drainage.

An adequate diagnosis should allow differentiating the underlying pathology and the side effects associated with the evolution of the pathology itself. These must be differentiated from the complications caused by the treatments applied and which have no direct link to the natural evolution of the pathology from which the patient is affected.