Chest Tube Drainage Devices

Placement of a chest tube drains intrapleural fluid and air. The tube should be attached to a drainage system, such as one-, two-, or three-compartment devices, a one-way (Heimlich) valve for ambulatory drainage, a digital system, or a vacuum bottle. The frequently employed three-compartment systems, currently integrated disposable units, allow adjustment of negative pressure or no suction (water seal), and include an air leak meter on the water seal chamber to be used for demonstrating and quantifying air leak. These readings are subjective and prone to interobserver variability. Digital pleural drainage systems offer the benefits of quantification of any air leak and pleural pressure. Indwelling pleural catheters, typically utilized for malignant pleural effusion, can be drained using vacuum bottles. Knowledge of the design and functionality of each device in the setting of an individual patient's specific pleural process facilitates the selection of practical and financially prudent chest tube drainage strategies.

Intrabronchial Valves for Air Leaks After Lobectomy, Segmentectomy, and Lung Volume Reduction Surgery

PURPOSE

Air leaks are common after lobectomy, segmentectomy, and lung volume reduction surgery (LVRS). This can increase post-operative morbidity, cost, and hospital length of stay. The management of post-pulmonary resection air leaks remains challenging. Minimally invasive effective interventions are necessary. The Spiration Valve System (SVS, Olympus/Spiration Inc., Redmond, WA, US) is approved by the FDA under humanitarian use exemption for management of prolonged air leaks.

METHODS

This is a prospective multicenter registry of 39 patients with air leaks after lobectomy, segmentectomy, and LVRS managed with an intention to use bronchoscopic SVS to resolve air leaks.

RESULTS

Bronchoscopic SVS placement was feasible in 82.1% of patients (32/39 patients) and 90 valves were placed with a median of 2 valves per patient (mean of 2.7 ± 1.5 valves, range of 1 to 7 valves). Positive response to SVS placement was documented in 76.9% of all patients (30/39 patients) and in 93.8% of patients when SVS placement was feasible (30/32 patients). Air leaks ultimately resolved when SVS placement was feasible in 87.5% of patients (28/32 patients), after a median of 2.5 days (mean ± SD of 8.9 ± 12.4 days). Considering all patients with an intention to treat analysis, bronchoscopic SVS procedure likely contributed to resolution of air leaks in 71.8% of patients (28/39 patients). The post-procedure median hospital stay was 4 days (mean 6.0 ± 6.1 days).

CONCLUSIONS

This prospective registry adds to the growing body of literature supporting feasible and effective management of air leaks utilizing one-way valves.

Endobronchial Valves for Challenging Air Leaks

BACKGROUND

Prolonged air leaks may result in increased morbidity and mortality. Endobronchial valves have been used as a nonoperative treatment. We evaluated the efficacy of endobronchial valves at achieving chest tube removal and hospital discharge for air leaks resulting from varied etiologies.

METHODS

All consecutive patients undergoing endobronchial valve placement for persistent air leak were evaluated by a multidisciplinary team at a single institution. Those receiving valves underwent bronchoscopy with balloon occlusion to identify airways contributing to the leak. After airway sizing, unidirectional endobronchial valves were deployed.

RESULTS

During an 18-month period, 21 patients underwent 24 valve placement procedures; 88 valves were placed (median, 3; mean, 3.6; range, 1 to 12). Patient age range was 16 months to 70 years. The underlying cause of persistent air leak was postoperative (n = 8), pneumothorax (n = 11), cavitary lung infection (n = 3), and postpneumonectomy bronchopleural fistula (n = 2). There were no valve-related complications during placement, dwell time, or removal. Three patients died as a result of their underlying disease, unrelated to valves. Of those with chest tubes who survived and were discharged, all had successful removal of their chest tubes. Median duration to chest tube removal after initial valve placement was 15 days (mean, 21 days; range, 0 to 86 days). Median length of stay after final valve placement was 5 days (mean, 15 days; range, 0 to 196 days).

CONCLUSIONS

Challenging air leaks often occur in medically compromised patients. They may persist despite multiple interventions. Endobronchial valves offer minimally invasive management. Time to chest tube removal and length of stay are variable, frequently because of clinical status and underlying disease.

Nodal stage of surgically resected non-small cell lung cancer and its effect on recurrence patterns and overall survival

PURPOSE

Current National Comprehensive Cancer Network guidelines recommend postoperative radiation therapy (PORT) for patients with resected non-small cell lung cancer (NSCLC) with N2 involvement. We investigated the relationship between nodal stage and local-regional recurrence (LR), distant recurrence (DR) and overall survival (OS) for patients having an R0 resection.

METHODS AND MATERIALS

A multi-institutional database of consecutive patients undergoing R0 resection for stage I-IIIA NSCLC from 1995 to 2008 was used. Patients receiving any radiation therapy before relapse were excluded. A total of 1241, 202, and 125 patients were identified with N0, N1, and N2 involvement, respectively; 161 patients received chemotherapy. Cumulative incidence rates were calculated for LR and DR as first sites of failure, and Kaplan-Meier estimates were made for OS. Competing risk analysis and proportional hazards models were used to examine LR, DR, and OS. Independent variables included age, sex, surgical procedure, extent of lymph node sampling, histology, lymphatic or vascular invasion, tumor size, tumor grade, chemotherapy, nodal stage, and visceral pleural invasion.

RESULTS

The median follow-up time was 28.7 months. Patients with N1 or N2 nodal stage had rates of LR similar to those of patients with N0 disease, but were at significantly increased risk for both DR (N1, hazard ratio [HR] = 1.84, 95% confidence interval [CI]: 1.30-2.59; P=.001; N2, HR = 2.32, 95% CI: 1.55-3.48; P<.001) and death (N1, HR = 1.46, 95% CI: 1.18-1.81; P<.001; N2, HR = 2.33, 95% CI: 1.78-3.04; P<.001). LR was associated with squamous histology, visceral pleural involvement, tumor size, age, wedge resection, and segmentectomy. The most frequent site of LR was the mediastinum.

CONCLUSIONS

Our investigation demonstrated that nodal stage is directly associated with DR and OS but not with LR. Thus, even some patients with, N0-N1 disease are at relatively high risk of local recurrence. Prospective identification of risk factors for local recurrence may aid in selecting an appropriate population for further study of postoperative radiation therapy.

Pleural space infections after image-guided percutaneous drainage of infected intraabdominal fluid collections: a retrospective single institution analysis

Background

Percutaneous drainage of infected intraabdominal fluid collections is preferred over surgical drainage due to lower morbidity and costs. However, it can be a challenging procedure and catheter insertion carries the potential to contaminate the pleural space from the abdomen. This retrospective analysis demonstrates the clinical and radiographic correlation between percutaneous drainage of infected intraabdominal collections and the development of iatrogenic pleural space infections.

Methods

A retrospective single institution analysis of 550 consecutive percutaneous drainage procedures for intraabdominal fluid collections was performed over 24 months. Patient charts and imaging were reviewed with regard to pleural space infections that were attributed to percutaneous drain placements. Institutional review board approval was obtained for conduct of the study.

Results

6/550 (1.1%) patients developed iatrogenic pleural space infections after percutaneous drainage of intraabdominal fluid collections. All 6 patients presented with respiratory symptoms and required pleural space drainage (either by needle aspiration or chest tube placement), 2 received intrapleural fibrinolytic therapy and 1 patient had to undergo surgical drainage. Pleural effusion cultures revealed same bacteria in both intraabdominal and pleural fluid in 3 (50%) cases. A video with a dynamic radiographic sequence demonstrating the contamination of the pleural space from percutaneous drainage of an infected intraabdominal collection is included.

Conclusions

Iatrogenic pleural space infections after percutaneous drainage of intraabdominal fluid collections occur at a low incidence, but the pleural empyema can be progressive requiring prompt chest tube drainage, intrapleural fibrinolytic therapy or even surgery. Expertise in intraabdominal drain placements, awareness and early recognition of this complication is critical to minimize incidence, morbidity and mortality in these patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12893-015-0030-4) contains supplementary material, which is available to authorized users.

Endobronchial occlusion with one-way endobronchial valves: a novel technique for persistent air leaks in children

PURPOSE

In children, persistent air leaks can result from pulmonary infection or barotrauma. Management strategies include surgery, prolonged pleural drainage, ventilator manipulation, and extracorporeal membrane oxygenation (ECMO). We report the use of endobronchial valve placement as an effective minimally invasive intervention for persistent air leaks in children.

METHODS

Children with refractory prolonged air leaks were evaluated by a multidisciplinary team (pediatric surgery, interventional pulmonology, pediatric intensive care, and thoracic surgery) for endobronchial valve placement. Flexible bronchoscopy was performed, and air leak location was isolated with balloon occlusion. Retrievable one-way endobronchial valves were placed.

RESULTS

Four children (16 months to 16 years) had prolonged air leaks following necrotizing pneumonia (2), lobectomy (1), and pneumatocele (1). Patients had 1-4 valves placed. Average time to air leak resolution was 12 days (range 0-39). Average duration to chest tube removal was 25 days (range 7-39). All four children had complete resolution of air leaks. All were discharged from the hospital. None required additional surgical interventions.

CONCLUSION

Endobronchial valve placement for prolonged air leaks owing to a variety of etiologies was effective in these children for treating air leaks, and their use may result in resolution of fistulae and avoidance of the morbidity of pulmonary surgery.

Endobronchial valve placement as destination therapy for recurrent pneumothorax in the setting of advanced malignancy

The development of a persistent air leak after pneumothorax can be encountered in patients with underlying structural lung disease. In those with advanced malignancy or other comorbidities, the ability to tolerate general anesthesia and thoracoscopic procedures may limit definitive management. We describe the case of a 68-y-old male with refractory acute myelogenous leukemia presenting with recurrent secondary spontaneous pneumothorax and persistent air leak related to an underlying fungal pneumonia. Endobronchial valve placement allowed for timely chest tube removal and discharge from the hospital, as well as avoidance of a thoracoscopic procedure and pleurodesis.

The use of convex probe endobronchial ultrasound-guided transbronchial needle aspiration in a pediatric population: a multicenter study

INTRODUCTION

The presence of intrathoracic lymphadenopathy and mediastinal masses in the pediatric population often presents a diagnostic challenge. With limited minimally invasive methodologies to obtain a diagnosis, invasive sampling via mediastinoscopy or thoracotomy is often pursued. Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive, outpatient procedure that has demonstrated significant success in the adult population in the evaluation of such abnormalities. Within the pediatric literature there is limited data regarding the use of EBUS-TBNA. We report the first multicenter review of a pediatric population undergoing EBUS-TBNA procedures identifying the feasibility, safety, utility, and outcomes of this procedure.

METHODS

All patients of 18 years of age or younger undergoing EBUS-TBNA at six major academic medical centers from the years 2007 through 2013 were reviewed. Data regarding procedural performance, outcomes, and complications were recorded.

RESULTS

A total of 21 patients meeting the inclusion criteria were identified in six centers. The mean age of the cohort was 13.7 (±4.1) years. EBUS-TBNA provided adequate sampling in 20/21 (95%) of the cases with diagnostic material obtained in 10 (48%) cases. Eight patients (38%) underwent additional surgical procedures to confirm or obtain diagnostic tissue. Within our cohort, 13 patients (62%) were able to avoid invasive surgical biopsy procedures. No procedural or anesthesia related complications were identified.

CONCLUSION

We report the first multicenter study to date confirming the feasibility and utility of EBUS-TBNA in the pediatric population. Due to the low overall procedural risk of EBUS-TBNA, it should be considered as a potential first line diagnostic option for children presenting with mediastinal or hilar abnormalities but further prospective studies are needed.

Would screening for lung cancer benefit 75- to 84-year-old residents of the United States?

Background: The National Lung Screening Trial demonstrated that screening for lung cancer improved overall survival (OS) and reduced lung cancer mortality in the 55- to 74-year-old age group by increasing the proportion of cancers detected at an early stage. Because of the increasing life expectancy of the American population, we investigated whether screening for lung cancer might benefit men and women aged 75–84 years.

Materials/Methods: Rates of non-small cell lung cancer (NSCLC) from 2000 to 2009 were calculated in both younger and older age groups using the surveillance epidemiology and end reporting database. OS and lung cancer-specific survival (LCSS) in patients with Stage I NSCLC diagnosed from 2004 to 2009 were analyzed to determine the effects of age and treatment.

Results: The per capita incidence of NSCLC decreased in the 55–74 cohort, but increased in the 75–84 cohort over the study period. Crude lung cancer death rates in the two age groups who had no specific treatment were 39.5 and 44.9%, respectively. These rates fell in both age groups when increasingly aggressive treatment was used. Rates of OS and LCSS improved significantly with increasingly aggressive treatment in the 75–84 age group. The survival benefits of increasingly aggressive treatment in 75- to 84-year-old females did not differ from their counterparts in the younger cohort.

Conclusion: Screening for lung cancer might be of benefit to individuals at increased risk of lung cancer in the 75–84 age group. The survival benefits of aggressive therapy are similar in females between 55–74 and 75–84 years old.

Endobronchial valve placement for spontaneous pneumothorax from stage IIIA non-small cell lung cancer facilitates neoadjuvant therapy

Spontaneous pneumothorax has previously been described as a presenting symptom of lung cancer. This presentation can, unfortunately, complicate and delay further definitive oncologic care until the pneumothorax can be effectively managed. We describe the case of a 58-year-old man who presented with secondary spontaneous pneumothorax and persistent air leak related to his primary lung carcinoma. Endobronchial valve placement allowed for the avoidance of pleurodesis, timely discharge, and neoadjuvant chemotherapy, followed by definitive surgical resection.

Specimen processing techniques for endobronchial ultrasound-guided transbronchial needle aspiration

BACKGROUND

Endobronchial ultrasound is used for sampling thoracic pathologic processes. Histologic examination may provide added diagnostic yield to cytologic preparations owing to superior assessment of architecture and immunohistochemistry. It remains unclear whether specific specimen processing technique impacts diagnostic yield. We hypothesized that diagnostic yield using histologic analysis of core needle biopsies is higher than cytologic preparations alone.

METHODS

We evaluated 177 consecutive patients with mediastinal abnormalities. An interventional pulmonologist or thoracic surgeon performed endobronchial ultrasound. We compared diagnostic yields of two specimen processing techniques, fixed slides (cytology) and formalin-fixed core samples (histology). Results were categorized as malignant, benign (infectious, inflammatory), normal nodal tissue, or inadequate sampling (nondiagnostic). Malignancy, a defined benign process, and normal lymph node were considered diagnostic.

RESULTS

The diagnostic yield for benign processes was higher by histologic examination (n = 37) than in cytologic preparations (n = 22; p = 0.0064). The diagnostic yield was comparable in malignancy (p = 0.7530). The combination of both techniques provided a higher overall diagnostic rate: 84% (n = 148) by histology, 82% (n = 146) by cytology, and 89% (n = 158) using both. Using two techniques revealed discordance in 23% (n = 40), demonstrating that the use of one technique alone would have resulted in missed diagnoses.

CONCLUSIONS

Adding histologic analysis of tissue cores obtained by endobronchial ultrasound offers higher diagnostic accuracy than only cytologic preparation of needle aspirates. Histologic and cytologic methods offer comparable diagnostic rates for malignancy. However, diagnostic yield for benign conditions is higher using histologic examination. Together, histology and cytology provide fewer missed diagnoses than either individually. When using endobronchial ultrasound, it is ideal to routinely use both needle aspirate cytology and core biopsy histology.