A Pleural Catheter Malposition through Diaphragm to Abdominal Cavity

A 78-old-man with history of diabetes mellitus and cerebral infarction was transferred to intensive care unit of Korea University Anam Hospital from nursing hospital. He presented with acute respiratory failure requiring mechanical ventilation caused by pneumonia and empyema. We inserted chest tube for empyema on the right side. A few days later, pleural effusion occurred on the left side. Thus, pleural catheter was inserted into left seventh intercostal space at the mid axillary line after marking of site using ultrasound. Chest simple radiography showed that the catheter direction had been inserted too downward (Figure 1A).