Recurrent pneumothoraces in ventilated patients despite ipsilateral chest tubes

Pneumothorax in acute respiratory distress syndrome on extracorporeal membrane oxygenation support

INTRODUCTION

Pneumothorax is associated with poor prognosis in patients with acute respiratory distress syndrome (ARDS). We sought to examine the outcomes of patients who are supported on veno-venous extracorporeal membrane oxygenation (VV ECMO) and develop a pneumothorax.

METHODS

We retrospectively reviewed all adult VV ECMO patients supported for ARDS between 8/2014-7/2020 at our institution, excluding patients with recent lung resection and trauma. Clinical outcomes were compared between patients with a pneumothorax to those without a pneumothorax.

RESULTS

Two hundred eighty patients with ARDS on VV ECMO were analyzed. Of those, 213 did not have a pneumothorax and 67 did. Patients with a pneumothorax had a longer duration of ECMO support (30 days [16-55] versus 12 [7-22], p < 0.001) and hospital length of stay (51 days [27-93] versus 29 [18-49], p < 0.001), and lower survival-to-discharge (58.2% versus 77.5%, p = 0.002) compared to patients without a pneumothorax. Controlling for age, BMI, sex, RESP score and pre-ECMO ventilator days, the odds ratio of survival-to-discharge was 0.41 (95% CI 0.22-0.78) in patients with a pneumothorax compared to those without. There was a lower incidence of significant bleeding when chest tubes were placed by proceduralist services (2.4% versus 16.2%, p = 0.03). Removal of the chest tube prior to ECMO decannulation compared to removal after decannulation was associated with need for replacement (14.3% versus 0%, p = 0.01).

CONCLUSION

Patients who develop a pneumothorax and are supported with VV ECMO for ARDS have longer duration on ECMO and decreased survival. Further studies are needed to assess risk factors for development of pneumothorax in this patient population.

Position of a chest tube at video-assisted thoracoscopic surgery for spontaneous pneumothorax

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is a good therapeutic option for young patients with primary spontaneous pneumothorax (PSP), but there sometimes exists unexpected prolonged hospital stay due to air leak after the operation.

OBJECTIVES

The goal of this retrospective study was to clarify if the position of the chest tube placed at VATS for PSP affected the periods of postoperative hospital stay.

METHODS

Seventy-one cases with PSP under age 40 who undertook VATS from January 1994 to February 2001 were examined for several factors. They were classified into two groups by the location of the tip of the chest tube placed at VATS as follows: upper medial pleural space (group I) and outside of there (group II).

RESULTS

Fifty-three of the 71 cases (75%) were classified in group I and 18 (25%) were in group II. Between the two groups, there were no differences as to preoperative characteristics of the patients and intraoperative findings of blebs or bullae. On the other hand, postoperative air leak-related complications were more frequent in group II than in group I (p=0.004). Mean postoperative hospital stay was 5.1+/-1.9 days in group I and 8.4+/-4.3 days in group II (p<0.0001).

CONCLUSIONS

Patients with the tip of the chest tube in the upper medial pleural space at VATS could be discharged earlier than the other patients. The chest tube placement is one of the important factors for the outcome of VATS for PSP.

Centromere DNA, proteins and kinetochore assembly in vertebrate cells

The centromere is a specialized region of the chromosome that is essential for faithful chromosome segregation during mitosis and meiosis in eukaryotic cells. It is the site at which the kinetochore, the functional nucleoprotein complex responsible for microtubule binding and chromosome movement, is assembled through complex molecular mechanisms. Herein, I review recent advances in our understanding of centromeric DNAs as sites for kinetochore assembly and the mechanisms underlying kinetochore assembly in vertebrate cells.

Diagnosis of pneumothorax in critically ill adults

The diagnosis of pneumothorax is established from the patients' history, physical examination and, where possible, by radiological investigations. Adult respiratory distress syndrome, pneumonia, and trauma are important predictors of pneumothorax, as are various practical procedures including mechanical ventilation, central line insertion, and surgical procedures in the thorax, head, and neck and abdomen. Examination should include an inspection of the ventilator observations and chest drainage systems as well as the patient's cardiovascular and respiratory systems.Radiological diagnosis is normally confined to plain frontal radiographs in the critically ill patient, although lateral images and computed tomography are also important. Situations are described where an abnormal lucency or an apparent lung edge may be confused with a pneumothorax. These may arise from outside the thoracic cavity or from lung abnormalities or abdominal viscera inside the chest.

Pleural Disease in the Intensive Care Unit

Pleural disease itself is an unusual cause for admission to the intensive care unit (ICU). Pleural complications of diseases and procedures in the ICU are common, however, and the impact on respiratory physiology is additive to that of the underlying cardiopulmonary disease. Pleural effusion and pneumothorax may be overlooked in the critically ill patient due to alterations in radiologic appearance in the supine patient. The development of a pneumothorax in a patient in the ICU represents a potentially life-threatening situation. This article reviews the etiologies, pathophysiology, and management of pleural effusion, pneumothorax, tension pneumothorax, and bronchopleural fistula in the critically ill patient. In addition, we review the potential complications of thoracentesis and chest tube thoracostomy, including re-expansion pulmonary edema.

Selective use of chest tubes in thoracotomies for congenital cardiovascular procedures

BACKGROUND

Advantages and complications have been reported from the use of chest tubes (CT). To reduce the incidence of complications we have employed a selective use of CT in thoracotomy for congenital cardiovascular procedure; ie, in absence of air leaks and fluid to be drained, no CT was inserted.

METHODS

The lung was reexpanded and air evacuated during the chest closure. Early and 6 hours chest roentgenograms were performed on every patient. This study retrospectively reviews the results of this selective approach in 546 patients operated on between 1980 and 1998 mainly for patent ductus arteriosum ligation, pulmonary artery band, aortic coarctation, Blalock-Taussig shunt. Four hundred and eighteen patients did not receive a CT at the initial surgery (group I), and 128 patients received a CT either before or at surgery (group II).

RESULTS

40 patients in group I developed an air or fluid collection large enough to require a CT. Only one patient had complication, from an undetected hemothorax. Nine patients in group II required another CT, and one patient developed a pneumothorax upon pulling out the CT. No death in either group was related to the use or lack of use of the CT. A total of 378 CTs and collecting chambers were saved.

CONCLUSIONS

A selective approach to the use of CT in thoracotomies for cardiovascular procedures can be employed with minimal complications, more comfort for the patient, and cost savings.

Analysis of tube thoracostomy performed by pulmonologists at a teaching hospital

STUDY OBJECTIVE

To evaluate all tube thoracostomies (TTs) done by pulmonary/critical care fellows and attending physicians in the Medical University of South Carolina's health-care system documenting patient demographics, indication for placement, size and characteristics of the tube, and associated problems.

DESIGN

Prospective.

SETTING

University health-care system, including a university hospital, a Veterans Affairs hospital, and a county hospital.

PATIENTS

All adult patients requiring consultation by a member of the pulmonary/critical care staff for a tube thoracostomy.

RESULTS

One hundred twenty-six tube thoracostomies were performed over a 24-month period in 91 patients. The most common initial indication for a TT was pneumothorax (69/103, 67%). Overall mortality in the patient population was 35% (32/91). Early problems (< 24 hours following placement) occurred in 3% (4/126); late problems (> 24 h after placement) occurred in 8% (10/126). Problems occurred in 36% (4/11) of small-bore tube placements vs 9% (10/115) of standard TT placements (p=0.02).

CONCLUSIONS

Tube thoracostomy can be safely performed by pulmonologists with relatively few associated problems.