Real-time ultrasound-guided pigtail catheter chest drain for complicated parapneumonic effusion and empyema in children - 16-year, single-centre experience of radiologically placed drains

Ultrasound-guided small-bore chest drain placement: a retrospective analysis of feasibility, safety and clinical implications in internal medicine ward

PURPOSE

Massive and complex pleural effusions represent a frequent challenge for internists, particularly when patients present with significant symptoms and the hospital setting lacks dedicated thoracic surgery or interventional pneumology services.

METHODS

This retrospective study evaluates the effectiveness and feasibility of ultrasound-guided small-bore chest drain placement performed by internal medicine physicians with interventional ultrasound experience. We analyze procedural success rates, complication profiles, and subsequent clinical management in a cohort of patients managed in a single internal medicine ultrasound ward.

RESULTS

In our series of ten patients, ultrasound-guided drain placement was successful in all cases. No immediate major complications were encountered, and subsequent complications were minimal and manageable.

CONCLUSION

Ultrasound-guided small-bore chest drain placement is a feasible, safe, and effective alternative to surgical chest tube insertion in selected patients in internal medicine wards, potentially avoiding the need for hospitalization or transfer to specialized thoracic surgery services.

Resident physician training in bedside pleural procedures: A one-year experience at a teaching hospital

BACKGROUND AND OBJECTIVE

This study aims to quantify bedside pleural procedures performed at a quaternary teaching hospital describing technical and epidemiological aspects.

MATERIALS AND METHODS

The authors retrospectively reviewed consecutive patients who underwent invasive thoracic bedside procedures between March 2022 and February 2023.

RESULTS

463 chest tube insertions and 200 thoracenteses were performed during the study period. Most procedures were conducted by 1st-year Thoracic Surgery residents, with Ultrasound Guidance (USG). There was a notable preference for small-bore pigtail catheters, with a low rate of immediate complications.

CONCLUSION

Bedside thoracic procedures are commonly performed in current medical practice and are significant in surgical resident training. The utilization of pigtail catheters and point-of-care ultrasonography by surgical residents in pleural procedures is increasingly prevalent and demonstrates high safety.

Efficacy, Safety, and Complications of Pigtail Thoracostomy for the Treatment of Pediatric Pleuropneumonia

OBJECTIVE

Pigtail thoracostomy (PT) has become the mainstay technique for the drainage of pediatric pleuropneumonic effusions (PLPe). However, its efficacy and complication profile has been questioned when compared with video-assisted thoracoscopic surgery and larger bore traditional tube thoracostomy. The aim of this study was to assess the efficacy, safety, and complications associated with PT.

METHODS

A cross-sectional study at a freestanding tertiary children's hospital. We extracted the medical records of all children aged younger than 18 years treated with PT for PLPe from June 2016 to June 2020. The primary efficacy outcome was treatment failure defined as the need for a repeat drainage procedure, thoracostomy, or video-assisted thoracoscopic surgery. Secondary efficacy outcomes were length of hospital stay (LOS) and duration of in situ PT. The primary safety outcomes were adverse events during or after insertion. We also recorded any associated complications.

RESULTS

During the study period, 55 children required PT. The median age was 25 months (interquartile range, 14-52) and 58.2% were boys. Eight (14.4%) were bacteremic or in septic shock. There were no adverse events related to insertion. Forty-two (76.3%) children were treated with fibrinolysis. There were 2 (3.6%) treatment failures. The median LOS and PT durations were 13 and 4 days (interquartile ranges, 10-14.8, 3-6.7), respectively. Eight (14.4%) children experienced complications that were nonoperatively managed.

CONCLUSIONS

Our findings suggest that PT drainage offers a safe and highly effective option for managing PLPe and carries a very low failure rate.

Percutaneous management of complicated empyema thoracis using pigtail, report of a case from University Hospital of Nepal: a case report

Empyema thoracis is a condition characterized by the accumulation of pus in the pleural cavity of the lungs. Empyema thoracis is a cause of high mortality in man and its occurrence is increasing in both children and adults. Traditionally, chest tube drainage has been a preferred method of treatment, but recent studies have shown that pigtail catheter drainage is a more effective and less invasive alternative. Image-guided drainage is also preferred over blind drainage, and alternative drainage sites are being explored. These management changes have improved patient outcomes and reduced the risk of complications.

CASE PRESENTATION AND CLINICAL DISCUSSION

A 66-year-old female presented with complaints of cough, fever, and chest pain. A clinical examination was done and relevant investigations were sent. She was then treated in the line of left-sided empyema thoracis. A pigtail catheter was inserted into the loculated empyema via the left 9th intercostal space through a posterolateral approach with ultrasonography guidance.

CONCLUSION

The main aim of this article is to provide an overview of a rare management approach for empyema, a condition characterized by the accumulation of pus in the pleural cavity of the lungs. In this case report, the authors have focused on pigtail catheter drainage over traditionally performed chest tube drainage, and image-guided drainage has been performed over blind drainage ensuring accurate placement and reducing the risk of damage to surrounding tissues. Another notable change in empyema management is the shift in drainage sites from the safety triangle to other sites based on the site of loculations under ultrasonography guidance.

Risk factors for complicated community-acquired pneumonia in children

BACKGROUND

Community-acquired pneumonia (CAP) in children continues to be one of the prominent causes of pediatric morbidity and mortality worldwide. By determining the risk factors associated with the development of complicated CAP (CCAP), new approaches for early diagnosis and effective treatment can be identified.

METHODS

This retrospective cohort study enrolled patients with CAP and CCAP who visited the pediatric ward of the study hospital between January 1, 2017 and December 31, 2017. For patients with CCAP, data regarding medical procedures performed, surgical intervention, and hospitalization duration were collected.

RESULTS

A total of 111 patients, 93 (83.7%) with CAP and 18 (16.3%) with CCAP, aged between 3 months and 18 years were hospitalized because of severe pneumonia. The mean age of the patients was 3.6 ± 1.2 years and 60 (54%) of them were female. The mean age of patients with CCAP was higher than that of patients with CAP (4.2 ± 3.3 vs. 2.8 ± 2.1 years respectively); however, the difference was not significant (p = 0.012). Patients with CCAP exhibited a significantly higher C-reactive protein level than those with CAP (10.06 ± 7.55 vs. 4.43 ± 3.37 g/L respectively; p = 0.007). Hypoxia upon admission was noted more commonly in the CCAP group than in the CAP group (p < 0.001).

CONCLUSION

Findings related to hypoxia, respiratory distress, and pleural effusion on imaging are important distinguishing factors associated with the development of complications in patients hospitalized with CAP. Therefore, CCAP etiology, diagnosis, and treatment approaches should be established and protective measures adopted.

Emergency Physician-Administered Sedation for Thoracostomy in Children With Pleuropneumonia

BACKGROUND

Thoracostomy drainage is sometimes required in children with pleuropneumonia who have large parapneumonic effusion. This procedure is usually performed under sedation. The aim was to report sedation adverse events (SAEs) in pneumonia patients sedated for thoracostomy by pediatric emergency physicians.

METHODS

A retrospective cohort study was conducted. The medical records of all emergency department patients who underwent thoracostomy between January 1, 2012, and December 31, 2018, were extracted. Study outcomes were SAEs that required intervention.

RESULTS

Pigtail catheters were placed by chest surgeons in 28 children with a median age of 2 years (interquartile range [IQR], 1-5 years). All the thoracostomies were successfully performed under sedation performed by 11 pediatric emergency physicians. The median amount of fluid drained after catheter insertion was 200 mL (IQR, 100-500 mL). The median pleural fluid PH was 7.0 (IQR, 6.9-7.3), and the median white blood cell count was 34,600 per mm3 (IQR, 11,800-109,000 per mm3). Thirteen patients (46.4%) were sedated with a total median dose of 3 mg/kg of ketamine (IQR, 2-4 mg/kg) and 0.2 mg/kg of midazolam (IQR, 0.2-0.3 mg/kg); 11 patients (39.3%) were treated with 1 mg/kg of ketamine (IQR, 0.5-2 mg/kg) and 3 mg/kg of propofol (IQR, 2-4 mg/kg). Four patients (14.3%) were treated exclusively with 4 mg/kg of ketamine (IQR, 3-5 mg/kg). Nine oxygen desaturations required intervention; 1 was associated with laryngospasm and 1 with apnea. All the SAEs were successfully managed. No cases of hypotension, bradycardia, airway obstruction, or pulmonary aspiration were recorded.

CONCLUSIONS

The first series of pneumonia patients sedated for thoracostomy by pediatric emergency physicians is reported. Sedation was safely performed in this cohort.

Challenges in Image-Guided Drainage of Infected Pleural Collections: A Review

Infected pleural fluid collections (IPFCs) commonly occur as a part of bacterial, fungal, or tubercular pneumonia or due to involvement of pleura through hematogenous route. Management requires early initiation of therapeutic drugs, as well as complete drainage of the fluid, to relieve patients’ symptoms and prevent pleural fibrosis. Image-guided drainage plays an important role in achieving these goals and improving outcomes. Intrapleural fibrinolytic therapy (IPFT) is also a vital component of the management. The concepts of image-guided drainage procedures, IPFT, and nonexpanding lung are discussed in this review.

The Application of Pigtail Catheters in Postoperative Drainage of Lung Cancer

BACKGROUND

Although minimally invasive surgery has been widely carried out at present, the postoperative pain of patients with lung cancer is still one of the difficult problems to solve in clinical practice.

OBJECTIVE

This study explored whether indwelling pigtail catheters after lung cancer surgery can help to reduce postoperative pain and promote the recovery of patients as soon as possible.

MATERIALS AND METHODS

From June 2018 to June 2020, patients who underwent thoracoscopic radical resection of lung cancer in our hospital were randomly divided into 2 groups: the pigtail catheter group and the control group. We compared the postoperative time of thoracic catheter removal, postoperative pain score, proportion of postoperative pleural effusion, postoperative hospitalization time, and postoperative complications of the 2 groups.

RESULTS

A total of 1375 patients were enrolled, including 677 patients in the pigtail catheter group and 698 patients in the control group. Compared with the control group, the pigtail catheter group had an earlier time of thoracic catheter removal, lower postoperative pain score, lower proportion of pleural effusion diagnosed by postoperative chest radiograph, and shorter postoperative average hospital stay, but there was no significant difference in postoperative complications.

CONCLUSION

The application of pigtail catheters after radical resection of lung cancer can reduce postoperative pain, accelerate the recovery of patients and shorten the postoperative hospital stay and is safe and reliable in clinical application.

Percutaneous management of complicated parapneumonic effusion and empyema after surgical tube thoracostomy failure in children: a retrospective study

PURPOSE

We aimed to evaluate the results of percutaneous management of complicated parapneumonic effusions (PPE) and empyema after surgical tube thoracostomy failure in children.

METHODS

A total of 84 children treated percutaneously after surgical tube thoracostomy failure between 2004 and 2019 were included to this retrospective study. Technical success was defined as appropriate placement of the drainage catheter. Clinical success was defined as complete resolution of infection both clinically and radiologically. Management protocol included imaging-guided pigtail catheter insertion, fibrinolytic therapy, serial ultrasonographic evaluation, catheter manipulations as necessary (revision, exchange, or upsizing), and appropriate antibiotherapy. All patients were followed up at least 6 months.

RESULTS

Technical success rate was 100%. Unilateral single, unilateral double, and bilateral catheter insertions were performed in 73, 9, and 2 patients, respectively. Inserted catheter sizes ranged from 8 F to 16 F. Streptokinase, urokinase, and tissue plasminogen activator were used as fibrinolytic agent in 29 (34%), 14 (17%), and 41 (49%) patients, respectively. In order to maintain effective drainage, 42 additional procedures (catheter exchange, revision, reposition, or additional catheter placement) were performed in 20 patients (24%). Clinical success was achieved in 83 of 84 patients (99%). Median catheter duration was 8 days (4-32 days). Median hospital stay during percutaneous management was 11.5 days (7-45 days). Factors affecting the median catheter duration were the presence of necrotizing pneumonia (p < 0.001) and bronchopleural fistulae (p < 0.001).

CONCLUSION

Percutaneous imaging-guided catheterization with fibrinolytic therapy should be the method of choice in pediatric complicated PPE and empyema patients with surgical tube thoracostomy failure. Percutaneous treatment is useful in avoiding more aggressive surgical options.

A decade's experience of pediatric lung abscess and empyema at a community hospital

BACKGROUND

Discussions on the diagnostic and management of acquired pediatric lung pathology are usually published by large tertiary children's hospitals. It is likely that much of this pathology is actually seen and managed in nonacademic practices.

METHODS

A 10-year retrospective review of patients under 18-years of age, treated for lung abscesses or empyema was performed.

RESULTS

Nineteen empyema and four lung abscesses were included. Presenting symptoms, workup, and management are reviewed. A unique subset (n = 4) of atypical pulmonary pathology is described. A 14-year-old with a vaping history and a lung abscess misdiagnosed as an empyema. A 15-year-old with primary pulmonary Hodgkin's lymphoma presenting as a lung abscess and empyema. A 5-year-old with an empyema complicated by a bronchopleural fistula and a 21-year-old with autism and an acquired lung cyst.

CONCLUSION

Our dilemmas, experiences, and strategies in managing complex lung disease are generalized to community-based practice.

Lung Ultrasound: Its Findings and New Applications in Neonatology and Pediatric Diseases

Lung ultrasound has become increasingly used in both adult and pediatric populations, allowing the rapid evaluation of many lung and pleura diseases. This popularity is due to several advantages of the method such as the low cost, rapidity, lack of ionizing radiation, availability of bedside and repeatability of the method. These features are even more important after the outbreak of the SARS-CoV-2 pandemic, given the possibility of recognizing through ultrasound the signs of interstitial lung syndrome typical of pneumonia caused by the virus. The purpose of this paper is to review the available evidence of lung ultrasound (LUS) in children and its main applications in pediatric diseases.

Consensus Document on Community-Acquired Pneumonia in Children. SENP-SEPAR-SEIP

Community-acquired pneumonia (CAP) is a prevalent disease among children and is frequently associated with both diagnostic and therapeutic uncertainties. Consensus has been reached between SEPAR, SENP and SEIP, and their conclusions are as follows.

Complicated pneumonia in children

Complicated community-acquired pneumonia in a previously well child is a severe illness characterised by combinations of local complications (eg, parapneumonic effusion, empyema, necrotising pneumonia, and lung abscess) and systemic complications (eg, bacteraemia, metastatic infection, multiorgan failure, acute respiratory distress syndrome, disseminated intravascular coagulation, and, rarely, death). Complicated community-acquired pneumonia should be suspected in any child with pneumonia not responding to appropriate antibiotic treatment within 48-72 h. Common causative organisms are Streptococcus pneumoniae and Staphylococcus aureus. Patients have initial imaging with chest radiography and ultrasound, which can also be used to assess the lung parenchyma, to identify pleural fluid; CT scanning is not usually indicated. Complicated pneumonia is treated with a prolonged course of intravenous antibiotics, and then oral antibiotics. The initial choice of antibiotic is guided by local microbiological knowledge and by subsequent positive cultures and molecular testing, including on pleural fluid if a drainage procedure is done. Information from pleural space imaging and drainage should guide the decision on whether to administer intrapleural fibrinolytics. Most patients are treated by drainage and more extensive surgery is rarely needed; in any event, in low-income and middle-income countries, resources for extensive surgeries are scarce. The clinical course of complicated community-acquired pneumonia can be prolonged, especially when patients have necrotising pneumonia, but complete recovery is the usual outcome.