A 73-year-old woman with metastatic adenocarcinoma of the lung including diffuse pulmonary involvement presented with profound dyspnea. An echocardiogram demonstrated a large circumferential pericardial effusion with tamponade physiology. Palliative echo-guided pericardiocentesis was performed, with removal of 550 mL of fluid, and a multi-sidehole pericardial catheter was left to gravity drainage. Despite evacuation of the effusion, the patient’s breathing remained labored, indicating that a substantial component of her dyspnea was related to pulmonary pathology. An echocardiogram the next morning showed a small pericardial effusion without findings of tamponade; however, a chest radiograph demonstrated extensive pneumopericardium (Figure). Syringe aspiration via the pericardial drain yielded 200 mL of fluid admixed with copious air.
Given the patient’s greatly increased respiratory effort, it was apparent that substantial negative intrathoracic pressure was being generated with each inspiration, causing air within or around the pericardial drain and collection system to be drawn into the pericardial space. Indeed, during inspiration, air bubbles in the drainage tubing were observed moving toward the patient. We confirmed proper drain position (no sideholes extended outside the pericardial space), and ensured that all drainage system connections were airtight. We also applied surgical gel to the skin to create an airtight seal around the drain. Pericardial drainage gradually tapered and no further air was noted. The patient was ultimately transitioned to hospice care and expired on the sixth postprocedure day.
Pneumopericardium is a rare event following pericardiocentesis and can result from either the creation of a communication between the pleural and pericardial spaces during the procedure, or from air leakage within or around the pericardial drainage system. While often a self-limited phenomenon, if under tension, a pneumopericardium can result in tamponade physiology with hemodynamic compromise.3 Prompt recognition and decompression is therefore critical. The diagnosis is typically made by detection of air bubbles on echocardiography, or by the classic radiographic findings described in our case. Treatment can involve removal of air by the techniques described above along with continued observation if a pericardial drain is still in place. If no drain is present and there is evidence of physiologic compromise, repeat pericardiocentesis or surgical decompression is necessary.
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-Craig R. Narins, MD, Junsoo Lee, MD, Melissa Cole, PA-C, Frederick S. Ling, MD
This article originally appeared in the September 2016 issue of The American Journal of Medicine.
