The article by way of Despars and colleagues that appears in this issue of Chest (see page 1147) formerly again brings to our attention an increasingly important issue: that of iatrogenous complications and their inherent harm to the patient and resultant increased charge for the healthcare system.

The article by way of Despars and colleagues that appears in this issue of Chest (see page 1147) formerly again brings to our attention an increasingly important issue: that of iatrogenous complications and their inherent harm to the patient and resultant increased charge for the healthcare system. Of all the iatrogenous complications related to usual diagnostic or therapeutic manner of proceedings pneumothorax is among the principally common. Its incidence has been reported to be from [les than] 1 to through 13 percent with central venous cannulation,[1-3] from 5 to 20 percent with thoracentesis and pleural biopsy,[4-6] from [les than] 1 to 3 percent with transbronchial lung biopsies,[7] from [les than or equal to] 10 percent to through 50 percent with transthoracic needle lung biopsy,[8-10] and from 1 percent to athwart 40 percent with positive squeezing mechanical ventilation.[11] The extremely wide range of reported incidence with about of these procedures obviously contemplates different patient populations, differences in technique, and/or different circumstances below which the data were consider probableed However, it also forcibly suggests that some standardization may be necessary to minimize the frequent occurrence with which this complication come to one's minds under comparable clinical circumstances. Unfortunately, popularly in many (most?) hospitals, exact harmonizing information on the incidence resulting from a specific course is not readily available in succession a hospitalwide basis. Thus, frequently it is not possible to establish whether one's performance is comparable to that of one's associates either within the same institution or elsewhere.

A previous article from the Veterans Administration National Cooperative contemplation on Spontaneous Pneumothorax[12] had reported forward the iatrogenous pneumothoraces prospectively identified in the 13 participating hospitals. Of the total of 538 iatrogenous pneumothoraces that were included, about 24 percent were caused from transthoracic lung biopsy, 22 percent from subclavian vein catheterization, 20 percent by means of thoracentesis, 10 percent by transbronchial lung biopsy, 8 percent by dint of pleural biopsy, 7 percent by way of positive pressure mechanical ventilation, and 9 percent through other miscellaneous causes. However, because the total number of each proceeding performed at participating institutions was not known, it was impossible to establish the truthful incidence of pneumothorax for each of them. Similarly, the data reported in the passing from hand to hand article were obtained at the Veterans Administration Hospital at lengthy Beach, Calif, and include 106 iatrogenous pneumothoraces prospectively identified between 1983 and 1988 Of these 106 pneumothoraces, approximately 33 percent were caused from transthoracic lung biopsy, 28 percent at thoracentesis, 22 percent by subclavian vein catheterization, and solely 7 percent by positive urgency mechanical ventilation.

Although the data of these sum of two units studies are similar, it is likely that significant differences may exist between hospitals, and thus, it appears highly advisable in today's healthcare environment that all hospitals should have agreeing monitoring of complications as part of their comprehensive quality assurance (or quality enhancement) programs. Specifically in regard to iatrogenous pneumothorax, it is of particular interest that in the couple studies quoted above, the incidence of spontaneous pneumothorax was substantially les than that of iatrogenous pneumothorax, and iatrogenous pneumothorax obviously carried significant added morbidity and calm mortality, not to mention a substantial added expense It is in this regard that the suggestion at Despars and colleagues that greatest in quantity iatrogenous pneumothoraces can be treated at simple aspiration of the pleural air merits special attention, since such a minimally invasive approach would be clearly safer and significantly les expensive. Using simple aspiration of the pleural air to treat a pneumothorax, iatrogenous or otherwise, is not a novel idea and its felicitous use has been reported in previous studies.[8,13,14] However, as evidenced on the nonuniform use of this approach reported through Despars et al, there is no universal agreement about when and/or in whom should this be the treatment of choice. Prospective studies to determine the validity of the recommendations made on the authors of this paper, and at others, are sorely needed. Similarly, propos ways to decrease the incidence of this complication subject to specific circumstances must also be carefully evaluated. For example, the use of ultrasound guidance to increase the safety of central vein cannulation[15] and/or of thoracentesis,[4] appears to be quite promising however must be prospectively studied. Using ultrasound to perform all of these courses would inevitably represent a substantial up-front price Thus, before recommending its widespread use, we must establish that it does indeed significantly increase patient safety, and maybe flat result in decreased overall healthcare outlays Finally, when or if a chest-tube thoracostomy is required to treat an iatrogenous pneumothorax, using a small-bore chest tube and a Heimlich valve device[8,16,17] instead of a "standard" large-bore chest tube and self-contained clos water-seal device, could be equally effective and potentially more comfortable for the patient and substantially les expensive. Again, prospective studies to determine the steady efficacy and limitations of this approach in a less degree than various clinical scenarios are destitutioned Unfortunately, in this era of molecular biology and genetic research, simple prospective studies to directly address eminently practical questions ofttimes lack in academic glamour, and thus, economic support to carry them not at home has become increasingly difficult to obtain. However, because of the substantial potential impact of the answers they provide, we must faith that these types of studies will not be completely ignored in our research-oriented universities and medical centers

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