# An Unusual Case of Intrapulmonary Placement of a Thoracic Drain

## TL;DR

A man with COPD suffered lung injury from a misplaced chest tube, requiring surgery and emphasizing the need for proper technique and imaging.

## Contribution

A case report highlighting rare but serious lung injury from chest tube insertion and the importance of proper technique and imaging.

## Key findings

- A chest tube traversed lung tissue in a COPD patient, causing persistent pneumothorax and subcutaneous emphysema.
- Surgical intervention, including mini thoracotomy and lung resection, was necessary for recovery.
- The case underscores the need for accurate imaging and proper technique to prevent iatrogenic lung injury.

## Abstract

Chest tube insertion for pneumothorax and other pleural diseases is a common and relatively minor procedure but carries risks such as iatrogenic lung injury, particularly in patients with preexisting lung disease or pleural adhesions. We present a case of lung injury following chest tube insertion in a Moroccan man with chronic obstructive pulmonary disease (COPD) and emphysematous lung disease. The chest tube traversed lung tissue, causing a persistent pneumothorax and subcutaneous emphysema. Surgical intervention, including mini thoracotomy, adhesiolysis, and lung resection, was required. The patient recovered satisfactorily. This report highlights the importance of correct technique, imaging for accurate tube placement, and timely surgical intervention in complicated cases. Although rare, lung injury caused by chest tube insertion is serious and warrants careful attention from trained caregivers.