Sudden dyspnea during central line removal: the air embolism sequence

How air enters during removal

A central vein sits close to the chest, where pressure can fall below atmospheric pressure when the client breathes in. When the catheter is withdrawn, the tract briefly connects the vein with room air. If the client inhales at that moment, or the site is left uncovered, air can be drawn into the vein and travel to the right side of the heart and the pulmonary circulation.

Clinical signs include sudden respiratory distress, chest pain, light-headedness, a pale and anxious appearance, tachycardia, tachypnoea, hypotension and hypoxia. These can appear during or soon after removal. Because they overlap with anxiety or a vasovagal faint, the timing next to an open central venous tract is the cue that points toward air embolism.

The emergency sequence in order

First stop further air entry by covering the site with a sterile occlusive dressing or firm gloved pressure. Then place the client on the left side with the head lowered, often called left lateral Trendelenburg. The aim is to keep air in the right side of the heart, away from the outflow to the lungs, so blood can keep moving. Evidence for this position is limited, but it remains standard teaching and protocol.

Give high-flow oxygen by non-rebreather mask, which supports oxygenation and helps the nitrogen in the bubble be absorbed. Call the rapid response team and provider without delay, stay with the client and monitor vital signs, saturation and level of consciousness. Prepare for resuscitation if the client deteriorates, and follow the team's further orders for fluids and treatment.

Removal steps that prevent it

Most prevention happens before the catheter moves. Unless contraindicated, the client lies flat with a head-down tilt for jugular and subclavian lines, though this is not needed for femoral lines. The client performs a Valsalva manoeuvre as the catheter is withdrawn; if they cannot, it is removed during expiration, when intrathoracic pressure is higher and air is less likely to be drawn in.

A sterile occlusive dressing goes on immediately after removal, and the client stays flat for a period set by local policy while the nurse observes for complications. Risk factors such as dehydration, inability to lie flat or uncontrolled coughing mean removal should go ahead only if it is safe to do so. The full step-by-step removal technique is a separate procedure skill.

After the emergency: observation and reporting

Once the client is stable, keep them under close observation, because neurological or cardiovascular effects can evolve. Watch level of consciousness, speech and limb movement as well as breathing and blood pressure, and report any new deficit at once. The provider may order further imaging or treatment depending on how the client responds.

Document the time of removal, the position and breathing technique used, symptom onset, every intervention and the client's response, and complete an incident report under local policy. Reviewing what happened helps the team spot avoidable causes, such as removal with the client sitting up or a delayed occlusive dressing, and reinforce safer practice.

Prioritise a hypothetical removal question

A hypothetical client sitting upright has a jugular line removed. Moments later they gasp, clutch their chest and become pale, with a rapid pulse and falling blood pressure. Options are to sit the client further upright to ease breathing, apply pressure to the site and lay the client on the left side head-down, check a blood glucose, or reassure the client and recheck vital signs in fifteen minutes.

Occluding the site and positioning the client left side head-down is the strongest answer, followed by oxygen and a call for help. Sitting upright is the instinct for breathlessness but does nothing to keep air away from the pulmonary outflow, glucose testing delays treatment, and reassurance ignores an emergency. Documentation and a review of removal technique come after the client is stable.

Sources and further reading

American Nurse Journal: Taking action against air embolism. Signs of venous air embolism, occlusive dressing, left lateral Trendelenburg positioning, high-flow oxygen, rapid response, and Valsalva and supine positioning during removal.

MSD Manual Professional: How to do infraclavicular subclavian vein cannulation (ultrasound-guided). Supine or head-down Trendelenburg positioning when central lines are inserted and removed, to help prevent air embolism.

Vascular air embolism. Stopping air entry, left lateral head-down (Durant) positioning to keep air at the right ventricular apex, and oxygen therapy in venous air embolism.