Heimlich valve and pneumothorax

Diagnostic and Therapeutic Characteristics in Patients with Pneumotorax Associated with COVID-19 versus Non-COVID-19 Pneumotorax

Introduction: Pneumothorax is a condition that usually occurs in thin, young people, especially in smokers. It is an unusual complication of COVID-19 disease that can be associated with worse results. This disease can occur without pre-existing lung disease or without mechanical ventilation. Materials and Methods: We present a monocentric comparative retrospective study of diagnostic and treatment analysis of two groups of patients diagnosed with COVID-19 and non-COVID-19 pneumothorax. All patients included in this study underwent surgery in a thoracic surgery department. The study was conducted over a period of 18 months. It included 34 patients with COVID-19 pneumothorax and 42 patients with non-COVID-19 pneumothorax. Results: The clinical symptoms were more intense in patients with COVID-19 pneumothorax. We found that the patients with COVID-19 had significantly more respiratory comorbidities. Diagnostic procedures include chest CT exam for both groups. Laboratory findings showed that increasing values for the analyzed data were consistent with the deterioration of the general condition and the appearance of pneumothorax in the COVID-19 group. The therapeutic attitude regarding the non-COVID-19 group was to eliminate the air from the pleural cavity and surgical approach to the lesion that determined the occurrence of pneumothorax. The group of patients with COVID-19 pneumothorax received systemic treatment, and only minimal pleurotomy was performed. The surgical approach did not alter patients’ survival. Conclusions: Careful monitoring of the patient’s clinic and laboratory tests evaluating the degradation of the lung parenchyma, correlated with the imaging examination (chest CT) is mandatory and reduces COVID-19 complications. Early imaging examination starts an effective diagnosis and treatment management. In severe COVID-19 pneumothorax cases, the pneumothorax did not influence the evolution of COVID-19 disease. When we found that the general condition worsened with the rapid progression of dyspnea and the deterioration of the general condition, and we found that it represented the progression or recurrence of pneumothorax.

Evaluation of oesophageal and gastric resection outcomes in a small-volume unit

Introduction

Oesophagogastric resections continue to be a major surgical challenge with high morbidity, this has led to a worldwide trend for centralisation of these complex surgeries. However, there is no clear agreement on what constitutes a high-volume centre, leading to worldwide disparity. We evaluate our experience of oesophagogastric resection in a small volume unit to seek other factors that influence patient outcome.

Methods

We analysed 173 consecutive oesophagogastric resection from 2010 to 2020. The primary outcome was 30-day mortality and secondary outcome included peri-operative morbidity, length of stay, lymph node harvest, R0 resection. Collected continuous data were compared using the Mann-Whitney test and categorical data using the chi-squared test and expressed as p value.

Results

Of the 173 patients, 94 (54%) underwent hybrid minimal invasive esophagectomy (HIMO) and 79 (46%) underwent gastrectomy. 135 (78%) patients received Neoadjuvant therapy. The site of tumour was GOJ in 29%, distal stomach in 26% and distal oesophagus in 20%. Perioperative morbidity was observed in 18 (19%) after esophagectomy and 9 (11.4%) after gastrectomy. The median lymph node harvest was 18 (range 5–42) and 168 patients (97%) had longitudinal R0 resection. The most common complication was neurological seen in 3.6% followed by pulmonary complication and anastomotic leak seen in 5 patients (3%) each. The median in hospital stay was 6 days and the 30 day mortality was 2.9% with one year survival of 87%.

Conclusion

Small volume centres can produce comparable results. The outcomes depend on multifold parameters which include surgeon's experience in the field, ability to adhere to protocols and procedures and strong interpersonal relationship with individual patients.

•

Centralisation of Oesophagogastric resection due to high risks of morbidity.

•

Comparable outcome at small volume center.

•

Benefits of continuity of care and building strong relationship with patients.

Compatibility and Safety Implications Associated with Interfacing Medical Devices in Neonatal Respiratory Care: A Case Example Using the Inhaled Nitric Oxide Delivery System

Over the past decade, international organizations have instituted strict regulations for the safe use of connected medical devices. The International Organization for Standardization and the Medical Device Single Audit Program instituted certifications to ensure that connected devices are compatible and operate within their proper clinical parameters. These efforts came about, in part, as a consequence of clinicians’ decisions to use nonstandard, modified, or improvised devices for purposes outside the original manufacturers’ approved parameters. Unapproved device modifications can be associated with increased risk of dosing errors, monitoring errors, tubing misconnections and serious or potentially fatal adverse events; furthermore, health care providers who implement unapproved device modifications may assume legal and financial liability should harm come to patients as a consequence of the modification. Using the inhaled nitric oxide delivery system as an example, the objective of this paper is to raise awareness of the potential dangers associated with unapproved modification and interfacing of therapeutic gas delivery systems and ventilators in the neonatal intensive care unit setting. The paper also highlights the rationale and necessity for rigorous validation processes that ensure that interfaced medical devices perform as intended in the clinical setting.

[Simulation of video-assisted retrieval of foreign bodies in the airway of children by nonmedical personnel]

BACKGROUND

Complete upper airway obstruction by a foreign body is a dramatic and acute emergency situation, and can result in rapid development of hypoxia, circulatory arrest and death. Special Magill pliers with an adjustable video optical system have been developed for airway inspection to facilitate efforts to remove foreign bodies causing obstruction of the upper airway.

OBJECTIVE

To remove a simulated airway foreign body from a cardiopulmonary resuscitation (CPR) manikin, either with normal Magill pliers or with the newly designed video Magill pliers.

MATERIAL AND METHODS

After a brief introduction, 81 kindergarten teachers, 51 pupils (age 10-14 years) and 52 prospective emergency physicians were asked to remove a 2 × 2 "Lego" brick from the hypopharynx of a CPR manikin using either standard Magill pliers or the newly designed video Magill pliers. The formal hypothesis was that there would be no differences between the methods. Successful removal was defined as when the first removal attempt resulted in the Lego brick passing beyond the teeth of the manikin within 60s.

RESULTS

The use of the video Magill pliers resulted in significantly higher success rates in removal of the simulated foreign airway body within 60 s compared to standard Magill pliers in kindergarten teachers (84% vs. 30%, p < 0.0001), pupils (84% vs. 18%, p < 0.0001) and prospective emergency physicians (92% vs. 40%, p < 0.0001). The time needed for removing the foreign airway body was significantly shorter in groups using the video Magill pliers (kindergarten teachers 29 ± 18s vs. 45 ± 19 s, pupils 29 ± 18s vs. 54 ± 14 s, and prospective emergency physicians 33 ± 18s vs. 45 ± 20 s; p < 0.0001). In an analogue points system (from 1 very simple to 10 extremely complicated), the user friendliness of the video Magill pliers was judged to be significantly higher than the standard Magill pliers (2.8 ± 1.6 vs. 7.8 ± 2.7 kindergarten teachers, 2.0 ± 1.3 vs. 7.2 ± 2.5 pupils and 3.2 ± 2.2 vs. 4.9 ± 3.1 prospective emergency physicians, p < 0.0001). Visibility of the airway foreign body was estimated to be significantly better employing the video Magill pliers compared to the standard Magill pliers (1.9 ± 1.4 vs. 9.8 ± 0.6 kindergarten teachers, pupils 1.3 ± 0.6 vs. 9.2 ± 1.6, prospective emergency physicians 2.3 ± 1.8 vs. 9.1 ± 2.3, p < 0.0001).

CONCLUSION

In this study kindergarten teachers, pupils (aged 10-14 years) and prospective emergency physicians had higher success rates in less time and reported better user friendliness and visibility using video Magill pliers compared to standard Magill pliers for removing a simulated foreign body from a CPR manikin airway.

Chest Tube Drainage of the Pleural Space: A Concise Review for Pulmonologists

Chest tube insertion is a common procedure usually done for the purpose of draining accumulated air or fluid in the pleural cavity. Small-bore chest tubes (≤14F) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients and pleural effusions in general, with the possible exception of hemothoraces and malignant effusions (for which an immediate pleurodesis is planned). Large-bore chest drains may be useful for very large air leaks, as well as post-ineffective trial with small-bore drains. Chest tube insertion should be guided by imaging, either bedside ultrasonography or, less commonly, computed tomography. The so-called trocar technique must be avoided. Instead, blunt dissection (for tubes >24F) or the Seldinger technique should be used. All chest tubes are connected to a drainage system device: flutter valve, underwater seal, electronic systems or, for indwelling pleural catheters (IPC), vacuum bottles. The classic, three-bottle drainage system requires either (external) wall suction or gravity (“water seal”) drainage (the former not being routinely recommended unless the latter is not effective). The optimal timing for tube removal is still a matter of controversy; however, the use of digital drainage systems facilitates informed and prudent decision-making in that area. A drain-clamping test before tube withdrawal is generally not advocated. Pain, drain blockage and accidental dislodgment are common complications of small-bore drains; the most dreaded complications include organ injury, hemothorax, infections, and re-expansion pulmonary edema. IPC represent a first-line palliative therapy of malignant pleural effusions in many centers. The optimal frequency of drainage, for IPC, has not been formally agreed upon or otherwise officially established.

Persistent air leaks: a review with an emphasis on bronchoscopic management

Persistent air leak (PAL) is a cause of significant morbidity in patients who have undergone lung surgery and those with significant parenchymal lung disease suffering from a pneumothorax. Its management can be complex and challenging. Although conservative treatment with chest drain and observation is usually effective, other invasive techniques are needed when conservative treatment fails. Surgical management and medical pleurodesis have long been the usual treatments for PAL. More recently numerous bronchoscopic procedures have been introduced to treat PAL in those patients who are poor candidates for surgery or who decline surgery. These techniques include bronchoscopic use of sealants, sclerosants, and various types of implanted devices. Recently, removable one-way valves have been developed that are able to be placed bronchoscopically in the affected airways, ameliorating air-leaks in patients who are not candidates for surgery. Future comparative trials are needed to refine our understanding of the indications, effectiveness, and complications of bronchoscopic techniques for treating PAL. The following article will review the basic principles of management of PAL particularly focusing on bronchoscopic techniques.

In-vitro evaluation of limitations and possibilities for the future use of intracorporeal gas exchangers placed in the upper lobe position

The lack of donor organs has led to the development of alternative "destination therapies", such as a bio-artificial lung (BA) for end-stage lung disease. Ultimately aiming at a fully implantable BA, general capabilities and limitations of different oxygenators were tested based on the model of BA positioning at the right upper lobe. Three different-sized oxygenators (neonatal, paediatric, and adult) were tested in a mock circulation loop regarding oxygenation and decarboxylation capacities for three respiratory pathologies. Blood flows were imitated by a roller pump, and respiration was imitated by a mechanical ventilator with different FiO₂ applications. Pressure drops across the oxygenators and the integrity of the gas-exchange hollow fibers were analyzed. The neonatal oxygenator proved to be insufficient regarding oxygenation and decarboxylation. Despite elevated pCO₂ levels, the paediatric and adult oxygenators delivered comparable sufficient oxygen levels, but sufficient decarboxylation across the oxygenators was ensured only at flow rates of 0.5 L min. Only the adult oxygenator indicated no significant pressure drops. For all tested conditions, gas-exchange hollow fibers remained intact. This is the first study showing the general feasibility of delivering sufficient levels of gas exchange to an intracorporeal BA via patient's breathing, without damaging gas-exchange hollow fiber membranes.

Re-discovering the Heimlich valve: Old wine in a new bottle

A 14-year-old boy came to our outpatient department with pleuritic chest pain and dyspnea. He was found to have a loculated empyema on the right side. He was taken up for surgery and decortication was done. He developed air leak in the postoperative period. When the air leak did not settle until the 10^th day, we decided to attach the atrium Pneumostat^™, a modified version of the Heimlich valve to his Intercostal drainage tube and sent him home. On further follow-up, his lung expanded, and ICD could be removed. The patient remains well until the current follow-up. We present this case in an attempt to change the perceptions about various options available to drain the chest. The Heimlich valve appears to be a more compliant option than the conventional underwater seal drainage in terms of early mobility, reduced length of stay, and patient compliance.