Persistent air leak secondary to pneumothorax in COVID-19: A case report and review of literature

An air leak is a pathologic communication between an area of the endobronchial tree and the pleural space, causing continued air flow. The communication can originate from a distal portion of the airway, causing an alveolar-pleural fistula, or from a more proximal airway, causing a bronchopleural fistula. When the air leak persists beyond 5-7 days, it is classified as persistent air leak (PAL). PAL has serious implications on patient management and outcomes, such as prolonged chest tube maintenance, high rate of infections, ventilation-perfusion mismatch, and prolonged hospital stay with higher morbidity and mortality. There are currently no guidelines for the management of PAL in COVID-19 patients. We presented a case of PAL in a patient with COVID-19-associated pneumothorax successfully treated with a one-way endobronchial valve. We also reviewed current published cases of PAL secondary to COVID-19-associated pneumothorax and the various methods they were treated. The first line treatment was insertion of one or more chest tubes, but the persistence of an air leak then led to other treatment modalities. Initial early surgical evaluation followed by pleurodesis is recommended for the management of PAL. The most common surgical approaches include VATS or open thoracotomy with mechanical or chemical pleurodesis or pleurectomy. However, surgery is not always a feasible option for critically ill patients. In such cases, there are multiple less invasive options for the management of PAL, including implantable devices, such as Watanabe spigots and stents, and chemical agents, such as thermal treatments, hemostatic substances, and tissue adhesives.

Empyema necessitans (EN) as a rare complication of tuberculosis - A case report

INTRODUCTION

Empyema necessitans (EN) is an uncommon condition where an intrathoracic empyema extends into surrounding extra-thoracic tissues. This case report presents a rare instance of tuberculous EN in an immunocompetent individual.

PRESENTATION OF CASE

We present a case of a healthy young male with complaints of weight loss and a chest wall swelling, initially treated as a subcutaneous abscess. He had a history of TB contact and initial laboratory tests showed elevated CRP and ESR, with no bacterial growth on initial culture from FNAC sample. Subsequent imaging revealed the presence of pleural empyema. Following surgical intervention, a connection between fluid collection outside the thoracic wall and the pleural cavity was identified. Diagnosis of tuberculous EN was made on results of second culture of the fluid collection. The patient was further treated with anti-tuberculous treatment.

DISCUSSION

EN, rare extrapulmonary complication of tuberculosis, is challenging to diagnose due to nonspecific symptoms and paucibacillary nature of extrapulmonary TB. Imaging plays a crucial role in diagnosis. A multidisciplinary approach involving surgery and anti-tuberculous treatment is effective in managing EN.

CONCLUSION

This case underscores the scarcity of EN occurrences and emphasizes the potential for latent TB to surface as atypical complications. Accurate diagnosis requires a combination of clinical insight, imaging, and laboratory tests. EN should be considered in individuals with chest wall masses, particularly in TB endemic areas, and those with a history of TB contact. Treatment involves surgical intervention and anti-tuberculous therapy.

Early Water Seal of Chest Tubes Following Video-Assisted Thoracic Surgery Pleurodesis

INTRODUCTION

Early water seal following minimally invasive pulmonary lobectomy has been shown to reduce chest tube duration and postoperative length of stay (LOS). We evaluated chest tube duration and postoperative LOS following a standardized chest tube management protocol change (water seal on postoperative day 1) after video-assisted thoracic surgery (VATS) pleurodesis.

METHODS

We identified adult patients undergoing VATS pleurodesis from August 2013 to December 2021. The chest tube protocol was changed in January 2017 such that patients were placed to water seal on the morning of postoperative day 1. Patients were divided into two groups, before the change (Group 1: August 2013-December 2016) and after (Group 2: January 2017-December 2021). We compared demographics, clinical characteristics, operative details, postoperative chest tube duration and output, and postoperative LOS between the groups. Descriptive statistics and log-transformed multivariable linear regression models were used to identify differences in patient outcomes that were associated with the protocol change.

RESULTS

A total of 488 patients underwent VATS pleurodesis during the study period (Group 1: 329 patients; Group 2: 159 patients). The median age was 61 y (interquartile range [IQR] 49-68), 51% were females, 69% were White, and 29% were Black. For postoperative LOS, Group 1 had an IQR of 3-7 d, while Group 2 had an IQR of 2-6 d (P < 0.001). The multivariable log-transformed linear regression models demonstrated that the practice change was associated with reduced chest tube duration (0.77 times the chest tube duration before the change; P < 0.001) and reduced LOS (0.81 times the LOS before the change; P = 0.006). There was an associated reduction in patients needing to return to the operating room (P = 0.048) and needing postoperative extended ventilatory support (P = 0.035).

CONCLUSIONS

Development of a standardized protocol to water seal chest tubes on postoperative day 1 following VATS pleurodesis is associated with reduced chest tube duration and LOS without an increase in postoperative complication rates.

The relationship between chest tube position in the thoracic cavity and treatment failure in patients with pleural infection: a retrospective cohort study

Background

Pleural infection is an infection of the pleural space that is usually treated with antibiotics and source control. Chest tube insertion is the most popular and widely used drainage technique. We typically attempt to place the tube at the bottom of the thoracic cavity to consider the effects of gravity; however, the effectiveness of this practice is not well-defined. Therefore, we aimed to examine whether the position of the tip of the thoracic tube affects treatment failure in patients with pleural infection.

Methods

In this retrospective observational study, patients with pleural infection who underwent thoracic tube insertion were divided into two groups: those with the tip of the tube positioned below the 10th thoracic vertebra at the level of the diaphragm (lower position group) and those with the tip placed above the 9th thoracic vertebra (upper position group). We compared whether the position of the tube tip affected treatment failure. Stabilized inverse probability treatment weights (SIPTW) were used to balance the baseline characteristics between the groups. Treatment failure showed a composite outcome of hospital death, referral to surgeons for surgery, and additional chest tube insertion.

Results

Among the 87 patients, 41 and 46 patients were in the lower and upper groups, respectively. No significant difference was observed in the composite outcomes between the groups (46.3% vs. 54.3%, P = 0.596). There was also no significant difference in the composite outcome between both groups after adjusting for SIPTW (52.3% vs. 68.8%, P = 0.286).

Conclusions

There were no significant differences in the treatment failure in this study addressing pleural infection treatment, in which the drain tip position was stratified by the 9th and 10th thoracic vertebrae. The position of the tip of the thoracic tube may not be important for pleural infection treatment providing that it is in the thoracic cavity.

Trial registration The participants were registered retrospectively.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02157-x.

Impact of Peer-Assisted Learning in Chest Tube Insertion Education on Surgical Residents

Objective

To investigate the impact of peer-assisted learning (PAL) in chest tube insertion education on surgical residents.

Methods

This study is a quasi-experimental study conducted on thirty general surgeon residents enrolled in the PAL program. They were divided into two learner groups (A and B) based on the period of residency start. Group A and B had six and one months of general surgery residency experience, respectively. All participants received adequate training for chest tube insertion by a recently graduated general surgeon. Chest tubes insertion skill was assessed using the tool for assessing chest tube insertion competency (TACTIC) test.

Results

Post-TACTIC test score was significantly higher (p=0.001) than Pre-TACTIC test score in both groups. However, a comparison of mean Pre-TACTIC test scores and mean Post-TACTIC test scores between group A and group B showed that PAL effectiveness in group A was significantly higher (p=0.001) than group B.

Conclusion

There was a positive relationship between the PAL program and the improvement of chest tube insertion technical skills in surgical residents. Based on our findings and similar studies, it can be concluded that the PAL program can increase the chest tube insertion skill of surgical residents.

Ambulant treatment with a digital chest tube for prolonged air leak is safe and effective

Background

Outpatient or ambulatory treatment for prolonged air leak (PAL) has been reported previously in various studies. Evidence regarding efficiency and safety is nevertheless poor. This report describes the experience of 10 years ambulatory care with a digital chest drain system monitored by specialized nurses in our centre. The aim of the study is to give further insights in the effectiveness and safety of this treatment.

Methods

Retrospective data of 10 years ambulatory care for PAL were examined. One hundred and forty patients with PAL after pneumothorax or pulmonary surgery were included.

Results

A total of 140 patients with PAL were included. Treatment was successful in 112 patients (80.0%). Hospital readmission was necessary in 33 patients (23.6%) and 28 (20.0%) of them received additional treatment. Additional treatment consisted of video-assisted thoracoscopic surgery (VATS) in 19 patients (13.6%), new chest tube placement in 8 patients (5.7%) and pleurodesis (with talc slurry) in 1 patient (0.7%). Minor complications occurred in 10 patients (7.1%), major complications requiring readmission occurred in 14 patients (10.0%).

Conclusions

Ambulatory treatment of PAL with a digital monitoring device resulted in a high success rate with a limited complication rate.

Massive Necrotizing Fasciitis of the Chest Wall: A Very Rare Case Report of a Closed Thoracostomy Complication

We present a case study of necrotizing fasciitis (NF), a very rare but dangerous complication of chest tube management. A 69-year-old man with shortness of breath underwent thoracostomy for chest tube placement and drainage with antibiotic treatment, followed by a computed tomography scan. He was diagnosed with thoracic empyema. Initially, a non-cardiovascular and thoracic surgeon managed the drainage, but the management was inappropriate. The patient developed NF at the tube site on the chest wall, requiring emergency fasciotomy and extensive surgical debridement. He was discharged without any complications after successful control of NF. A thoracic surgeon can perform both tube thoracostomy and tube management directly to avoid complications, as delayed drainage might result in severe complications.

Cervical Spine Reconstruction with Chest Tube Technique After Metastasis Resection: A Single-Center Experience

BACKGROUND

The silastic tube technique, in which a chest tube is placed into the vertebral body defect and impregnated with polymethyl methacrylate, showed good results in patients with lumbar and thoracic neoplastic diseases. There has been only 1 study about the effectiveness and safety of this technique in patients with cervical metastases. We aimed to report our experience in using this technique to reconstruct the spine after corpectomy for cervical metastasis.

METHODS

All patients with cervical spinal metastasis who underwent surgical treatment using a chest tube impregnated with polymethyl methacrylate in conjunction with anterior cervical plate stabilization were retrospectively recruited. Demographics, tumor histology, revised Tokuhashi score, preoperative and postoperative American Spinal Injury Association score, preoperative and postoperative ambulatory status, perioperative complications, and survival time were collected.

RESULTS

This study included 16 patients. The most common primary tumor site was the lung (6 patients; 37.5%). The mean (SD) survival time was 408 (401) days (range, 1-2797 days), and the median survival time was 72 days (95% confidence interval 28-116 days). Four patients (25%) died within 30 postoperative days. There was no surgical site infection or instrument failure after the surgery. Five patients (31.2%) lived >180 days, and 3 patients (18.8%) lived >360 days. One patient (6.2%) was still alive at the end of the study.

CONCLUSIONS

The silastic tube technique in conjunction with anterior cervical plate stabilization might be safe, effective, and cost-effective for patients with cervical spine metastasis.

A Risk Reduction Technique for Five Invasive Procedures in the Emergency Room Using a Compact and Lightweight X-ray Unit

BACKGROUND

Many invasive procedures are performed in the emergency room (ER), which have potential risks and complications. Due to limitations, especially with respect to size, portable X-ray devices are generally not used during such procedures. However, they have been miniaturized, enabling physicians to capture X-ray images by themselves..

METHODS

We developed a safe, compact, and lightweight X-ray unit and performed five invasive procedures in the ER. In all the procedures, a chest X-ray image was taken to confirm its utility.

RESULTS

Case 1 (central venous catheter placement): After needle and guidewire insertion and the placement of the catheter, the location of catheter could be confirmed. Case 2 (chest tube insertion): During the insertion of the chest tube into the pleural space, it was observed that the tip of the thoracic tube was at the appropriate location. Case 3 (percutaneous tracheostomy or cricothyroidotomy): After needle and guidewire insertion, it was visualized that the guidewire was in the right main bronchus and that the tube was inserted into the trachea. Case 4 (resuscitative endovascular aortic balloon of the aorta): The captured image revealed that the catheter was located in zone I before balloon inflation. Case 5 (Sengstaken-Blakemore tube): The image revealed that the balloon was located in the stomach.

CONCLUSIONS

The devised portable X-ray unit could contribute medical safety during invasive procedures frequently performed in the ER.

[Ambulatory management of bilateral secondary spontaneous pneumothorax in palliative care]

INTRODUCTION

Secondary spontaneous pneumothoraces account for 35% of all pneumothoraces after the age of 50. Their management is still debated and can be challenging due to the underlying respiratory condition. In our observation, the use of small-bore chest tubes allowed prolonged ambulatory care in a palliative setting.

CASE REPORT

We report the case of a 54-year-old woman suffering from a leiomyosarcoma with multiple pulmonary metastases who had repeated episodes of pneumothorax, one of which was bilateral. Treatment involved the bilateral insertion of 8.5F pigtail catheters connected to Heimlich valves that allowed management as an outpatient. Recurrences were treated similarly, in association with oncological management, providing great additional benefits for patient comfort in this palliative context.

CONCLUSION

Altogether, this case report confirms the applicability of outpatient management for drained spontaneous secondary pneumothoraces, even bilateral, especially in a palliative-care setting.

Image-guided chest tube drainage in the management of chylothorax post cardiac surgery in children: a single-center case series

BACKGROUND

In children, chylothorax post cardiac surgery can be difficult to treat, may run a protracted course, and remains a source of morbidity and mortality.

OBJECTIVE

To analyze the experience with percutaneous image-guided chest-tube drainage in the management of post-cardiac-surgery chylothoraces in children.

MATERIALS AND METHODS

We conducted a single-center retrospective case series of 37 post-cardiac-surgery chylothoraces in 34 children (20 boys; 59%), requiring 48 drainage procedures with placement of 53 image-guided chest tubes over the time period 2004 to 2015. We analyzed clinical and procedural details, adverse events and outcomes. Median age was 0.6 years, median weight 7.2 kg.

RESULTS

Attempted treatments of chylothoraces prior to image-guided chest tubes included dietary restrictions (32/37, 86%), octreotide (12/37, 32%), steroids (7/37, 19%) and thoracic duct ligation (5/37, 14%). Image-guided chest tubes (n=43/53, 81%) were single unilateral in 29 children, bilateral in 4 (n=8/53, 15%), and there were two ipsilateral tubes in one (2/53, 4%). Effusions were isolated, walled-off, in 33/53 (62%). In 20/48 procedures (42%) effusions were septated/complex. The mean drainage through image-guided chest tubes was 17.3 mL/kg in the first 24 h, and 13.4 mL/kg/day from diagnosis to chest tube removal; total mean drainage from all chest tubes was 19.6 mL/kg/day. Nine major and 27 minor maintenance procedures were required during 1,207 tube-days (rate: 30 maintenance/1,000 tube-days). Median tube dwell time was 21 days (range 4-57 days). There were eight mild adverse events, three moderate adverse events and no severe adverse events related to image-guided chest tubes. Radiologic resolution was achieved in 26/37 (70%). Twenty-three children (68%) survived to discharge; 11 children (32%) died from underlying cardiac disease.

CONCLUSION

Management of chylothorax post-cardiac-surgery in children is multidisciplinary, requiring concomitant multipronged approaches, often through a protracted course. Multiple image-guided chest tube drainages can help achieve resolution with few complications. Interventional radiology involvement in tube care and maintenance is required. Overall, mortality remains high.

Overuse of small chest drains for pleural effusions: a retrospective practice review

PURPOSE

Small-bore drains (≤ 16 Fr) are used in many centers to manage all pleural effusions. The goal of this study was to determine the proportion of avoidable chest drains and associated complications when a strategy of routine chest drain insertion is in place.

DESIGN/METHODOLOGY/APPROACH

We retrospectively reviewed consecutive pleural procedures performed in the Radiology Department of the McGill University Health Centre over one year (August 2015-July 2016). Drain insertion was the default drainage strategy. An interdisciplinary workgroup established criteria for drain insertion, namely: pneumothorax, pleural infection (confirmed/highly suspected), massive effusion (more than 2/3 of hemithorax with severe dyspnea /hypoxemia), effusions in ventilated patients and hemothorax. Drains inserted without any of these criteria were deemed potentially avoidable.

FINDINGS

A total of 288 procedures performed in 205 patients were reviewed: 249 (86.5%) drain insertions and 39 (13.5%) thoracenteses. Out of 249 chest drains, 113 (45.4%) were placed in the absence of drain insertion criteria and were deemed potentially avoidable. Of those, 33.6% were inserted for malignant effusions (without subsequent pleurodesis) and 34.5% for transudative effusions (median drainage duration of 2 and 4 days, respectively). Major complications were seen in 21.5% of all procedures. Pneumothorax requiring intervention (2.1%), bleeding (0.7%) and organ puncture or drain misplacement (2%) only occurred with drain insertion. Narcotics were prescribed more frequently following drain insertion vs. thoracentesis (27.1% vs. 9.1%, p = 0.03).

ORIGINALITY/VALUE

Routine use of chest drains for pleural effusions leads to avoidable drain insertions in a large proportion of cases and causes unnecessary harms.

Pneumothorax detection in chest radiographs: optimizing artificial intelligence system for accuracy and confounding bias reduction using in-image annotations in algorithm training

OBJECTIVES

Diagnostic accuracy of artificial intelligence (AI) pneumothorax (PTX) detection in chest radiographs (CXR) is limited by the noisy annotation quality of public training data and confounding thoracic tubes (TT). We hypothesize that in-image annotations of the dehiscent visceral pleura for algorithm training boosts algorithm's performance and suppresses confounders.

METHODS

Our single-center evaluation cohort of 3062 supine CXRs includes 760 PTX-positive cases with radiological annotations of PTX size and inserted TTs. Three step-by-step improved algorithms (differing in algorithm architecture, training data from public datasets/clinical sites, and in-image annotations included in algorithm training) were characterized by area under the receiver operating characteristics (AUROC) in detailed subgroup analyses and referenced to the well-established "CheXNet" algorithm.

RESULTS

Performances of established algorithms exclusively trained on publicly available data without in-image annotations are limited to AUROCs of 0.778 and strongly biased towards TTs that can completely eliminate algorithm's discriminative power in individual subgroups. Contrarily, our final "algorithm 2" which was trained on a lower number of images but additionally with in-image annotations of the dehiscent pleura achieved an overall AUROC of 0.877 for unilateral PTX detection with a significantly reduced TT-related confounding bias.

CONCLUSIONS

We demonstrated strong limitations of an established PTX-detecting AI algorithm that can be significantly reduced by designing an AI system capable of learning to both classify and localize PTX. Our results are aimed at drawing attention to the necessity of high-quality in-image localization in training data to reduce the risks of unintentionally biasing the training process of pathology-detecting AI algorithms.

KEY POINTS

• Established pneumothorax-detecting artificial intelligence algorithms trained on public training data are strongly limited and biased by confounding thoracic tubes. • We used high-quality in-image annotated training data to effectively boost algorithm performance and suppress the impact of confounding thoracic tubes. • Based on our results, we hypothesize that even hidden confounders might be effectively addressed by in-image annotations of pathology-related image features.

Massive Necrotizing Fasciitis of the Chest Wall: A Very Rare Case Report of a Closed Thoracostomy Complication

We present a case study of necrotizing fasciitis (NF), a very rare but dangerous complication of chest tube management. A 69-year-old man with shortness of breath underwent thoracostomy for chest tube placement and drainage with antibiotic treatment, followed by a computed tomography scan. He was diagnosed with thoracic empyema. Initially, a non-cardiovascular and thoracic surgeon managed the drainage, but the management was inappropriate. The patient developed NF at the tube site on the chest wall, requiring emergency fasciotomy and extensive surgical debridement. He was discharged without any complications after successful control of NF. A thoracic surgeon can perform both tube thoracostomy and tube management directly to avoid complications, as delayed drainage might result in severe complications.

Digital versus analogue chest drainage system in patients with primary spontaneous pneumothorax: a randomized controlled trial

BACKGROUND

Patients with a primary spontaneous pneumothorax (PSP) who are treated with chest tube drainage are traditionally connected to an analogue chest drainage system, containing a water seal and using a visual method of monitoring air leakage. Electronic systems with continuous digital monitoring of air leakage provide better insight into actual air leakage and changes in leakage over time, which may lead to a shorter length of hospital stay.

METHODS

We performed a randomized controlled trial comparing the digital with analogue system, with the aim of demonstrating that use of a digital drainage system in PSP leads to a shorter hospital stay.

RESULTS

In 102 patients enrolled with PSP we found no differences in total duration of chest tube drainage and hospital stay between the groups. However, in a post-hoc analysis, excluding 19 patients needing surgery due to prolonged air leakage, hospital stay was significantly shorter in the digital group (median 1 days, IQR 1-5 days) compared to the analogue group (median 3 days, IQR 2-5 days) (p 0.014). Treatment failure occurred in 3 patients in both groups; the rate of recurrence within 12 weeks was not significantly different between groups (16% in the digital group versus 8% in the analogue group, p 0.339).

CONCLUSION

Length of hospital stay was not shorter in patients with PSP when applying a digital drainage system compared to an analogue drainage system. However, in the large subgroup of uncomplicated PSP, a significant reduction in duration of drainage and hospital stay was demonstrated with digital drainage. These findings suggest that digital drainage may be a practical alternative to manual aspiration in the management of PSP.

TRIAL REGISTRATION

Registered 22 September 2013 - Retrospectively registered, Trial NL4022 (NTR4195).

Efficacy and Cost-Effectiveness of Portable Small-Bore Chest Tube (Thoracic Egg Catheter) in Spontaneous Pneumothorax

Background

Primary spontaneous pneumothorax is commonly treated with chest tube insertion, which requires hospitalization. In this study, we evaluated the efficacy, costs, and benefits of a portable small-bore chest tube (Thoracic Egg; Sumitomo Bakelite Co. Ltd., Tokyo, Japan) compared with a conventional chest tube.

Methods

We retrospectively analyzed all primary spontaneous pneumothorax patients who underwent treatment at Gangnam Severance Hospital between August 2014 and May 2018.

Results

A total of 279 patients were divided into 2 groups: the conventional group (n=236) and the Thoracic Egg group (n=43). Of the 236 patients in the conventional group, 100 were excluded because they underwent surgery during the study period. The efficacy and cost were compared between the 2 groups. There was no statistically significant difference between the groups regarding recurrence (conventional group, 36 patients [26.5%]; Thoracic Egg group, 15 patients [29.4%]; p=0.287). However, the Egg group had statistically significantly lower mean medical expenses than the conventional group (433,413 Korean won and 522,146 Korean won, respectively; p<0.001).

Conclusion

Although portable small-bore chest tubes may not be significantly more efficacious than conventional chest tubes, their use is significantly less expensive. We believe that the Thoracic Egg catheter could be a less costly alternative to conventional chest tube insertion.

Intrapleural Impedance Sensor Real-Time Tracking of Pneumothorax in a Porcine Model of Air Leak

In patients with alveolar-to-pleural air leak due to recent surgery or trauma, clinicians tend to manage chest tubes with suction therapy. Nonsuction therapy is associated with shorter chest tube duration but also a higher risk of pneumothorax. We sought to develop an intrapleural electrical impedance sensor for continuous, real-time monitoring of pneumothorax development in a porcine model of air leak as a means of promoting nonsuction therapy. Using thoracoscopy, 2 chest tubes and the pleural impedance sensor were introduced into the pleural space of 3 pigs. Continuous air leak was introduced through 1 chest tube by carbon dioxide insufflation. The second chest tube was placed to suction then transitioned to no suction at increasingly higher air leaks until pneumothorax developed. Simultaneously, real-time impedance measurements were obtained from the pleural sensor. Fluoroscopy spot images were captured to verify the presence or absence of pneumothorax. Statistical Analysis Software was used throughout. With the chest tube on suction, a fully expanded lung was identified by a distinct pleural electrical impedance respiratory waveform. With transition of the chest tube to water seal, loss of contact of the sensor with the lung resulted in an immediate measurement of infinite electrical impedance. Pneumothorax resolution by restoring suction therapy was detected in real time by a return of the normal respiratory impedance waveform. Pleural electrical impedance monitoring detected pneumothorax development and resolution in real time. This simple technology has the potential to improve the safety and quality of chest tube management.

The utility of the Stapler with PGA sheet for pulmonary wedge resection: a propensity score-matched analysis

Background

Air leakage is a common complication after pulmonary wedge resection. The aim of this study was to evaluate the effect of staple line reinforcement in reducing air leakage after pulmonary wedge resection.

Methods

A retrospective analysis was performed on patients who underwent pulmonary wedge resection. The patients were classified into 2 groups; the Stapler with polyglycolic acid sheet was used for the reinforced and the Stapler without polyglycolic acid sheet was used for the non-reinforced group. The patients were matched one-to-one based on a propensity score that comprised several patient characteristics. A propensity score-matched analysis was performed to compare patient outcomes.

Results

A total of 291 patients who met the inclusion criteria were investigated. There were 165 in the reinforced group and 126 patients in the non-reinforced group. Propensity score analysis generated 104 matched pairs of patients in both the reinforced and the non-reinforced groups. The rate of non-placement of chest tube was significantly higher in the reinforced group than in the non-reinforced group (61.5% vs. 36.5%; P<0.001). The rate of postoperative air leakage was higher in the non-reinforced group than in the reinforced group (13.5% vs. 1.9%, P<0.001). On logistic regression analysis, not using the reinforcement device was one of the independent factors related to pulmonary air leakage after pulmonary wedge resection (OR: 8.58, P<0.001).

Conclusions

The use of the Stapler with polyglycolic acid sheet during pulmonary wedge resection increased the rate of intraoperative chest tube removal and reduced the rate of postoperative air leakage.

Facing the challenges of perioperative air leaks using water seal in Colombia

Air leaks following thoracic surgery continue to be a significant cause of morbidity and mortality. In contemporary thoracic surgery, many aspects of post-surgical air leaks are still controversial. In developing countries like Colombia, state-of-the-art technology such as newer digital drainage systems are not always available, and surgeons rely primarily on water seal systems for air leak management. Although efforts are being made to increase the use of newer digital systems, being a third-world country has its challenges, and we emphasize the importance of following international guidelines as much as possible, especially when facing complex situations such as perioperative air leaks with limited resources.

Comparison of a novel, endoscopic chest tube insertion technique versus the standard, open technique performed by novice users in a human cadaver model: a randomized, crossover, assessor-blinded study

Background

The technique of tube thoracostomy has been standardized for years without significant updates. Alternative procedural methods may be beneficial in certain prehospital and inpatient environments with limited resources. We sought to compare the efficacy of chest tube insertion using a novel, endoscopic device (The Reactor™) to standard, open tube thoracostomy.

Methods

Novice users were randomly assigned to pre-specified sequences of six chest tube insertions performed on a human cadaver model in a crossover design, alternating between the Reactor™ and standard technique. All subjects received standardized training in both procedures prior to randomization. Insertion site, which was randomly assigned within each cadaver’s hemithorax, was marked by the investigators; study techniques began with skin incision and ended with tube insertion. Adequacy of tube placement (intrapleural, unkinked, not in fissure) and incision length were recorded by investigators blinded to procedural technique. Insertion time and user-rated difficulty were documented in an unblinded fashion. After completing the study, participants rated various aspects of use of the Reactor™ compared to the standard technique in a survey evaluation.

Results

Sixteen subjects were enrolled (7 medical students, 9 paramedics) and performed 92 chest tube insertions (n = 46 Reactor™, n = 46 standard). The Reactor™ was associated with less frequent appropriate tube positioning (41.3% vs. 73.9%, P = 0.0029), a faster median insertion time (47.3 s, interquartile range 38–63.1 vs. 76.9 s, interquartile range 55.3–106.9, P < 0.0001) and shorter median incision length (28 mm, interquartile range 23–30 vs. 32 mm, interquartile range 26–40, P = 0.0034) compared to the standard technique. Using a 10-point Likert scale (1-easiest, 10-hardest) participants rated the ease of use of the Reactor™ no different from the standard method (3.8 ± 1.9 vs. 4.7 ± 1.9, P = 0.024). The Reactor™ received generally favorable scores for all parameters on the post-participation survey.

Conclusions

In this randomized, assessor-blinded, crossover human cadaver study, chest tube insertion using the Reactor™ device resulted in faster insertion time and shorter incision length, but less frequent appropriate tube placement compared with the standard technique. Additional studies are needed to evaluate the efficacy, safety and potential advantages of this novel device.

Randomized controlled trial on the comparison of chest tube drainage and needle aspiration in the treatment of primary spontaneous pneumothorax

Objectives

To evaluate the efficacy of the chest tube drainage (CTD) and the needle aspiration (NA) in the treatment of primary Spontaneous pneumothorax (SP).

Methods

In a randomized controlled trial, seventy patients suffering SP were divided equally into two subgroups, as follows: (A) CTD and (B) NA. The immediate and one-week rate of the treatments was the primary endpoints. Postoperative complications, length of hospital stay and incidence of pneumothorax recurrence during one-year follow up were also recorded.

Results

The immediate success of treatment was 68.5% and 54.2% of patients in CTD and NA groups, respectively that showed no significant difference between study groups (P: 0.16). The complete lung expansion after one week observed in 32 (91.4%) of NA group and 33 (94.2%) patients in CTD group (P: 0.5). Pneumothorax recurrence was detected in 13 patients (4 in NA and 9 in CTD group) (P: 0.11). Mean pain intensity was significantly lower in the NA group at the first hour after the procedure, the first postoperative day and the first week after the intervention (P< 0.001).

Conclusion

Needle aspiration (NA) can be applied as a first step treatment in patients with primary SP, considering its advantages.

Factors predicting the need for tube thoracostomy in patients with iatrogenic pneumothorax associated with computed tomography-guided transthoracic needle biopsy

Objectives

Traumatic iatrogenic pneumothorax occurs most often after a transthoracic needle biopsy. Since this procedure has become a common outpatient intervention, emergency department admissions of post-biopsy pneumothorax patients have increased. The aim of this study was to determine the factors that predict the need for tube thoracostomy in patients with post-biopsy pneumothorax in the emergency department.

Methods

A retrospective cross-sectional study was conducted on 191 patients with post-biopsy pneumothorax who were admitted to the emergency department between 2010 and 2017. Patient characteristics, clinical findings at the emergency department presentation, and procedural and radiological features were reviewed. A multivariate logistic regression model was constructed using the variables from univariate comparisons to determine the need for tube thoracostomy in patients with iatrogenic pneumothorax, and the effect sizes were demonstrated with odds ratios.

Results

Tube thoracostomies were performed on 69 out of 191 patients (36.1%). A total of 122 patients (63.9%) were treated with supplemental oxygen therapy without any other intervention, and 126 patients (66.0%) were hospitalized. In the multivariate model, the variables predicting the need for a tube thoracostomy were decreased breath sounds, dyspnea, decreased systolic blood pressure, decreased oxygen saturation and increased pleura–lesion distance. A distance of 19.7 mm predicted the need with a sensitivity of 69.6% and a specificity of 62.3%.

Conclusion

Decreased breath sounds, dyspnea, decreased systolic blood pressure, decreased oxygen saturation, and increased pleura-lesion distance may predict the need for a tube thoracostomy in patients with post-biopsy pneumothorax.

Feasibility and Safety of a New Chest Drain Wound Closure Method with Knotless Sutures

Background

A method of wound closure using knotless suture material in the chest tube site has been introduced at our center, and is now widely used as the primary method of closing chest tube wounds in video- assisted thoracic surgery (VATS) because it provides cosmetic benefits and causes less pain.

Methods

We included 109 patients who underwent VATS pulmonary resection at Samsung Medical Center from October 1 to October 31, 2016. Eighty-five patients underwent VATS pulmonary resection with chest drain wound closure utilizing knotless suture material, and 24 patients underwent VATS pulmonary resection with chest drain wound closure by the conventional method. Complications related to the chest drain wound were compared between the 2 groups.

Results

There were 2 cases of pneumothorax after chest tube removal in both groups (8.3% in the conventional group, 2.3% in the knotless suture group; p=0.172) and there was 1 case of wound discharge due to wound dehiscence in the knotless suture group (0% in the conventional group, 1.2% in the knotless suture group; p=0.453). There was no reported case of chest tube dislodgement in either group. The complication rates were non-significantly different between the 2 groups.

Conclusion

The results for the complication rates of this new chest drain wound closure method suggest that this method is not inferior to the conventional method. Chest drain wound closure using knotless suture material is feasible based on the short-term results of the complication rate.

Pleural electrical impedance is a sensitive, real-time indicator of pneumothorax

BACKGROUND

Chest tube management protocols, particularly in patients with alveolar-pleural air leak due to recent surgery or trauma, are limited by concerns over safety, especially concerns about rapid and occult development of pneumothorax. A continuous, real-time monitor of pneumothorax could improve the quality and safety of chest tube management. We developed a rat model of pneumothorax to test a novel approach of measuring electrical impedance within the pleural space as a monitor of lung expansion.

MATERIALS AND METHODS

Anesthetized Sprague-Dawley rats underwent right thoracotomy. A novel impedance sensor and a thoracostomy tube were introduced into the right pleural space. Pneumothorax of varying volumes ranging from 0.2 to 20 mL was created by syringe injection of air via the thoracostomy tube. Electrical resistance measurements from the pleural sensor and fluoroscopic images were obtained at baseline and after the creation of pneumothorax and results compared.

RESULTS

A statistically significant, dose-dependent increase in electrical resistance was observed with increasing volume of pneumothorax. Resistance measurement allowed for continuous, real-time monitoring of pneumothorax development and the ability to track pneumothorax resolution by aspiration of air via the thoracostomy tube. Pleural resistance measurement demonstrated 100% sensitivity and specificity for all volumes of pneumothorax tested and was significantly more sensitive for pneumothorax detection than fluoroscopy.

CONCLUSIONS

The electrical impedance-based pleural space sensor described in this study provided sensitive and specific pneumothorax detection, which was superior to radiographic analysis. Real-time, continuous monitoring for pneumothorax has the potential to improve the safety, quality, and efficiency of postoperative chest tube management.

Pleural drainage using drainage bag for thoracoscopic lobectomy

Objective This study was designed to compare the effectiveness and convenience of a drainage bag and a chest bottle following thoracoscopic lobectomy. Methods We conducted a test to ensure that the drainage bag was characterized by easy drainage and an antireflux effect. Thereafter, the drainage bag was used in all thoracic operations in our service. To understand the usefulness of the drainage bag, a retrospective cohort study enrolled 30 patients who had a drainage bag after thoracoscopic lobectomy and compared them with 30 similar patients operated on previously who had chest bottles. Variables studied included total drainage volume, duration of drainage, complications, and satisfaction of the care providers. Results There was no significant difference between the chest bottle and drainage bag groups respectively in terms of total drainage (697.5 ± 89.7 vs. 614.1 ± 76.6 mL, p = 0.483) or duration of drainage (4.23 ± 0.38 vs. 4.43 ± 0.38 days, p = 0.713). No device-related complication was observed. After our experience with the drainage bag, we abandoned use of the chest bottle. The drainage bag was more convenient for patients and promoted early ambulation as well improving cost effectiveness. Most care providers preferred to use the drainage bag (p = 0.000). Conclusion The drainage bag is superior to the chest bottle for postoperative drainage.

A pleural vacuum relief device for pleural drain unit use in the hyperbaric environment

INTRODUCTION

When a standard water-seal pleural drain unit (PDU) is used under hyperbaric conditions there are scenarios where excessive negative intrapleural pressure (IPP) and/or fluid reflux can be induced, risking significant morbidity. We developed and tested a pleural vacuum relief (PVR) device which automatically manages these risks, whilst allowing more rapid hyperbaric pressure change rates.

METHODS

The custom-made PVR device consists of a one-way pressure relief valve connected in line with a sterile micro filter selected for its specific flow capacity. The PVR device is designed for connection to the patient side sampling port of a PDU system, allowing inflow of ambient air whenever negative pressure is present, creating a small, controlled air leak which prevents excessive negative pressure. The hyperbaric performance of a Pleur-Evac A-6000 intercostal drain was assessed with and without this added device by measuring simulated IPP with an electronic pressure monitor connected at the patient end of the PDU. IPP readings were taken at 10, 15, 20 and 30 cmH₂O of suction (set on the drain unit) at compression rates of 10, 30, 60, 80, 90 and 180 kPa·min⁻¹ to a pressure of 280 kPa.

RESULTS

At any compression rate of > 10 kPa·min⁻¹, the negative IPP generated by the Pleur-Evac A-6000 alone was excessive and resulted in back flow through the PDU water seal. By adding the PVR device, the generated negative IPP remains within a clinically acceptable range, allowing compression rates of at least 30 kPa·min⁻¹ with suction settings up to -20 cmH₂O during all phases of hyperbaric treatment.

CONCLUSIONS

The PDU PVR device we have developed works well, minimising attendant workload and automatically avoiding the excessive negative IPPs that can otherwise occur. This device should only be used with suction.

Early pleural fluid dynamics following video-assisted thoracoscopic lobectomy has limited clinical value

The objective of this study was to evaluate the potential of predicting the pleural fluid output in patients after video-assisted thoracoscopic lobectomy of the lung. Detailed measurements of continuous fluid output were obtained prospectively using an electronic thoracic drainage device (Thopaz+™, Medela AG, Switzerland). Patients were divided into high (≥500 mL) and low (<500 mL) 24-hour fluid output, and detailed flow curves were plotted graphically to identify arithmetic patterns predicting fluid output in the early (≤24 hours) and later (24-48 hours) post-operative phase. Furthermore, multiple logistic regression analysis was used to predict high 24-hour fluid output using baseline data. Data were obtained from 50 patients, where 52% had a fluid output of <500 mL/24 hours. From visual assessment of flow curves, patients were grouped according to fluid output 6 hours postoperatively. An output ≥200 mL/6 hours was predictive of 'high 24-hour fluid output' (P<0.0001). However, 33% of patients with <200 mL/6 hours ended with a 'high 24-hour fluid output'. Baseline data showed no predictive value of fluid production, and 24-hour fluid output had no predictive value of fluid output between 24 and 48 hours. Assessment of initial fluid production may predict high 24-hour fluid output (≥500 mL) but seems to lack clinical value in drain removal criteria.

[Pleural cavity concerns]

INTRODUCTION

Persistent air leak (PAL) is a common problem. We asses our experience in the management of these patients.

MATERIAL AND METHODS

Retrospective review of patients with chest tubes after bronchopulmonary pneumothorax (due to lung resections, spontaneous pneumothorax, necrotizing pneumonia) from 2010 to 2015. We studied clinical data, PAL incidence, risk factors and treatment, considering PAL ≥ 5 days.

RESULTS

Thirty-seven cases (28 patients) between 0-16years: 26 lung resections, 11 pneumothorax. We found no differences in the distribution of age, weight, indication or comorbidity, but we noticed a trend to shorter hospital stay in infants. Patients with staple-line reinforcement presented lower PAL incidence than patients with no mechanical suture (43% vs 37%), the difference is even apparent when applying tissue sealants (29% vs 50%) (p > 0.05). We encountered no relationship between the size of the tube (10-24 Fr) or the type of resection, with bigger air leaks the higher suction pressure. We performed 13 pleurodesis in 7 patients (2 lobectomies, 3 segmentectomies and 2 bronchopleural fistulas), with 70% effectiveness. We conducted 7 procedures with autologous blood (1.6 ml/kg), 2 with povidone-iodine (0.5 ml/kg), 2 mechanical thoracoscopic and 2 open ones. We repeated pleurodesis four times, 3 of them after autologous blood infusion: 2 infusions with the same dose (both effective) and the other 2 as thoracotomy in patients with bronchopleural fistulas. After instillation of blood 3 patients presented with fever. After povidone-iodine instillation, the patient suffered from fever and rash.

CONCLUSIONS

Intraoperative technical aspects are essential to reduce the risk of PAL. Autologous blood pleurodesis, single or repeated, is a minimal invasive option, very safe and effective to treat the parenchymatous PAL.

Randomized controlled trial of chest tube removal aided by a party balloon

Background Recurrent pneumothorax is one of the most common complications after thoracostomy tube removal. The purpose of this study was to assess the optimal method of thoracostomy tube removal by comparing party balloon-assisted Valsalva and classic Valsalva techniques. Methods Trauma patients with indications for tube thoracostomy from 2014 to 2015 were recruited. Exclusion criteria were age < 15- or > 64-years-old, history of chronic lung disease, Glasgow Coma Scale < 13, latex allergy, or tracheostomy. Participants were randomly allocated by randomized block design into 4 groups using different Valsalva maneuvers: group A: classic inspired, group B: classic expired, group C: balloon-inspired; and group D: balloon-expired. The primary and secondary outcomes were recurrent pneumothorax and respiratory complications. Results Forty-eight tube thoracostomies were randomized for analysis; 4 patients had bilateral tube thoracostomies. The mean patient age was 38.1 ± 19.9 years. The incidence of recurrent pneumothorax confirmed by chest radiography was 15.4% in group A, 16.8% in group B, and none in groups C and D ( p = 0.31). When group A combined with group B was compared with groups C and D, the incidence was 16% vs. 0%, respectively ( p = 0.11). The thoracostomy tube reinsertion rate in all 4 groups was 0%, 8.33%, 0%, and 0%, respectively, which was not significant ( p = 0.38). Conclusions Performing the Valsalva maneuver correctly during full inspiration may be the method of choice for removing thoracostomy tubes. Using a party balloon forces the patient perform the Valsalva maneuver adequately and is simpler to explain.

Intrapleural Dornase and Tissue Plasminogen Activator in pediatric empyema (DTPA): a study protocol for a randomized controlled trial

BACKGROUND

A randomized controlled trial of adults with empyema recently demonstrated decreased length of stay in hospital in patients treated with intrapleurally administered dornase alfa and fibrinolytics compared to fibrinolytics alone. Whether this treatment strategy is safe and effective in children remains unknown.

METHODS/DESIGN

This study protocol is for a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. The participants are previously well children admitted to a children's hospital with a diagnosis of empyema requiring chest tube insertion and fibrinolytics administered intrapleurally. Children will be randomized after the treating physician has decided that pleural drainage is required but prior to chest tube insertion. After chest tube insertion, participants in the treatment group will receive intrapleurally administered tissue plasminogen activator (tPA) 4 mg followed by dornase alfa 5 mg. Participants in the placebo group will receive tPA 4 mg followed by normal saline. Study treatments will be administered once daily for 3 days. All participants, parents or caregivers, clinicians, and research personnel will remain blinded. The primary outcome is length of stay from chest tube insertion to discharge from hospital. Secondary outcomes include time to meeting discharge criteria, chest tube duration, fever duration, need for additional procedures, adverse events, hospital readmission, cost of hospitalization, and mortality.

DISCUSSION

This multicenter randomized controlled trial will assess the safety, effectiveness, and cost-effectiveness of combined treatment with dornase alfa and fibrinolytics compared to fibrinolytics alone for the treatment of empyema in children.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01717742 . Registered on 8 October 2012.

Evaluation of the necessity for chest drain placement following thoracoscopic wedge resection

PURPOSE

To evaluate the outcomes of patients who underwent thoracoscopic wedge resection without chest drain placement.

METHODS

The subjects of this retrospective study were 89 patients, who underwent thoracoscopic wedge resection at our hospital between January, 2013 and July, 2015. A total of 45 patients whose underlying condition did not meet the following criteria were assigned to the "chest drain placement group" (group A): peripheral lesions, healthy lung parenchyma, no intraoperative air leaks, hemorrhage or effusion accumulation, and no pleural adhesion. The other 44 patients whose underlying condition met the criteria were assigned to the "no chest drain placement group" (group B). Patient characteristics, specimen data, and postoperative conditions were analyzed and compared between the groups.

RESULTS

Group A patients had poorer forced expiratory volume in one second (FEV1) values, less normal spirometric results, significantly higher resected lung volume, a greater maximum tumor-pleura distance, and a larger maximum tumor size. They also had a longer postoperative hospital stay. There was no difference between the two groups in postoperative complications.

CONCLUSIONS

Avoiding chest drain placement after a thoracoscopic wedge resection appears to be safe and beneficial for patients who have small peripheral lesions and healthy lung parenchyma.

Role Of Clamping Tube Thoracostomy Prior To Removal In Non-Cardiac Thoracic Trauma

BACKGROUND

The frequently encountered thoracic trauma in surgical emergencies is a major cause of mortality and morbidity. Eighty percent of thoracic trauma can be managed by simple insertion of tube thoracostomy. Though guidelines for insertion are comprehensively explained in literature, an ideal algorithm for discontinuation is not available. A standard and safe defined protocol would eliminate hesitancy in confident removal among general surgeons. The objective of this study was to determine role of clamping trial prior to removal in terms of frequency of recurrent pneumothorax.

METHODS

This study was conducted in department of Surgery Combined military hospital/Military Hospital Rawalpindi from April 2013 to March 2014. Total 180 patients with blunt or penetrating thoracic trauma were included in the study. Chest tube (28-36 Fr) was inserted in Trauma centre under strict asepsis. Tubes were then connected to under water seal for minimum six hours. Patients were randomly divided in two equal groups (90 in each). In Group A, Clamping trial was given before attempting removal while in Group B, tube was removed immediately without clamping trial. Patients of both groups were observed two hourly for development of recurrent pneumothorax. Data was analysed using SPSS-18.

RESULTS

The comparison of frequency of recurrent pneumothorax in Group A (9 patients, 10%) and in Group B (4 patients, 4.5%) was not found to be statistically significant. (p-value 2.073).

CONCLUSIONS

Clamping trial is unnecessary prior to removal of tube thoracostomy in blunt and penetrating non-cardiac thoracic trauma in terms of recurrent pneumothorax.

Outpatient Treatment for Pneumothorax Using a Portable Small-Bore Chest Tube: A Clinical Report

Background

For treatment of pneumothorax in Korea, many institutions hospitalize the patient after chest tube insertion. In this study, a portable small-bore chest tube (Thoracic Egg; Sumitomo Bakelite Co. Ltd., Tokyo, Japan) was used for pneumothorax management in an outpatient clinic.

Methods

Between August 2014 and March 2015, 56 pneumothorax patients were treated using the Thoracic Egg.

Results

After Thoracic Egg insertion, 44 patients (78.6%) were discharged from the emergency room for follow-up in the outpatient clinic, and 12 patients (21.4%) were hospitalized. The mean duration of Thoracic Egg chest tube placement was 4.8 days, and the success rate was 73%; 20% of patients showed incomplete expansion and underwent video-assisted thoracoscopic surgery. For primary spontaneous pneumothorax patients, the success rate of the Thoracic Egg was 76.6% and for iatrogenic pneumothorax, it was 100%. There were 2 complications using the Thoracic Egg.

Conclusion

Outpatient treatment of pneumothorax using the Thoracic Egg could be a good treatment option for primary spontaneous and iatrogenic pneumothorax.

Are some children with empyema at risk for treatment failure with fibrinolytics? A multicenter cohort study

BACKGROUND

Guidelines recommend that children with empyema be treated initially with chest tube insertion and intrapleural fibrinolytics. Some patients have poor outcomes with this approach, and it is unclear which factors are associated with treatment failure.

METHODS

Possible risk factors were identified through a review of the literature. Treatment failure was defined as need for repeat pleural drainage and/or total length of stay greater than 2weeks.

RESULTS

We retrospectively identified 314 children with empyema treated with fibrinolytics at The Hospital for Sick Children (2000-2013, n=195), Children's Hospital, London Health Sciences Centre (2009-2013, n=39), and McMaster Children's Hospital (2007-2014, n=80). Median length of stay was 11days (range 5-69days). Thirteen percent of children required repeat drainage procedures, and 34% experienced treatment failure. There were no deaths. White blood cell count, erythrocyte sedimentation rate, C-reactive protein, albumin, urea to creatinine ratio, and signs of necrosis on initial chest x-ray were not associated with treatment failure. Multivariable logistic regression demonstrated increased risk with positive blood culture (odds ratio=2.7), immediate admission to intensive care (odds ratio=2.6), and absence of complex septations on baseline ultrasound (odds ratio=2.1). Male gender and platelet count were associated with treatment failure in the univariate analysis but not in the multivariable model.

CONCLUSIONS

Predicting which children with empyema are at risk for treatment failure with fibrinolytics remains challenging. Risk factors include positive blood culture, immediate admission to intensive care, and absence of complex septations on ultrasound. Routine blood work and inflammatory markers have little prognostic value.

Tube thoracostomy training with a medical simulator is associated with faster, more successful performance of the procedure

Objective

Tube thoracostomy (TT) is a commonly performed intensive care procedure. Simulator training may be a good alternative method for TT training, compared with conventional methods such as apprenticeship and animal skills laboratory. However, there is insufficient evidence supporting use of a simulator. The aim of this study is to determine whether training with medical simulator is associated with faster TT process, compared to conventional training without simulator.

Methods

This is a simulation study. Eligible participants were emergency medicine residents with very few (≤3 times) TT experience. Participants were randomized to two groups: the conventional training group, and the simulator training group. While the simulator training group used the simulator to train TT, the conventional training group watched the instructor performing TT on a cadaver. After training, all participants performed a TT on a cadaver. The performance quality was measured as correct placement and time delay. Subjects were graded if they had difficulty on process.

Results

Estimated median procedure time was 228 seconds in the conventional training group and 75 seconds in the simulator training group, with statistical significance (P=0.040). The difficulty grading did not show any significant difference among groups (overall performance scale, 2 vs. 3; P=0.094).

Conclusion

Tube thoracostomy training with a medical simulator, when compared to no simulator training, is associated with a significantly faster procedure, when performed on a human cadaver.

Pneumothorax with prolonged chest tube requirement after CT-guided percutaneous lung biopsy: incidence and risk factors

PURPOSE

To evaluate the incidence and risk factors of pneumothoraces requiring prolonged maintenance of a chest tube following CT-guided percutaneous lung biopsy in a retrospective, single-centre case series.

MATERIALS AND METHODS

All patients undergoing CT-guided percutaneous lung biopsies between June 2012 and May 2014 who required chest tube insertion for symptomatic or enlarging pneumothoraces were identified. Based on chest tube dwell time, patients were divided into two groups: short term (0-2 days) or prolonged (3 or more days). The following risk factors were stratified between groups: patient demographics, target lesion characteristics, and procedural/periprocedural technique and outcomes.

RESULTS

A total of 2337 patients underwent lung biopsy; 543 developed pneumothorax (23.2 %), 187 required chest tube placement (8.0 %), and 55 required a chest tube for 3 days or more (2.9 % of all biopsies, 29.9 % of all chest tubes). The median chest tube dwell time for short-term and prolonged groups was 1.0 days and 4.7 days, respectively. The transfissural needle path predicted prolonged chest tube requirement (OR: 2.5; p = 0.023). Other factors were not significantly different between groups.

CONCLUSION

Of patients undergoing CT-guided lung biopsy, 2.9 % required a chest tube for 3 or more days. Transfissural needle path during biopsy was a risk factor for prolonged chest tube requirement.

KEY POINTS

• CT-guided percutaneous lung biopsy (CPLB) is an important method for diagnosing lung lesions • A total of 2.9 % of patients require a chest tube for ≥3 days following CPLB • Transfissural needle path is a risk factor for prolonged chest tube time.

Right main bronchial fracture resolution by digital thoracic drainage system

Tracheobronchial stenosis is common in the thoracic surgery service, and iatrogenic injury of the airway after manipulation is not infrequent. When a digital thoracic drainage system came onto the market, many advantages were evident. A 24-year-old woman with critical right main bronchial stenosis underwent airway dilation that was complicated by a tear with a massive air leak, resulting in a total right pneumothorax. We employed a pleural drain connected to a digital thoracic drainage system. The drain was removed 2 days after successful resolution of the air leak.

Post-ECMO chest tube placement: A propensity score-matched survival analysis

BACKGROUND

Severe morbidity and mortality has been reported from chest tube (CT) placement during pediatric extracorporeal membrane oxygenation (ECMO).

METHODS

Kids' Inpatient Database (KID) was analyzed for ECMO with CT placed <8days postcannulation (1997-2009).

RESULTS

Overall, 5884 patients were identified (213 CT) (56% male, 49% white), with a median (IQR) age at ECMO cannulation 7 (117)days, length of stay (LOS) 26 (35)days, and total charges (TC) 342,116 (409,573) USD. Diagnoses included congenital diaphragmatic hernia (CDH) 16%, meconium aspiration (MA) 2%, pulmonary hypertension (PH) 13%, respiratory distress syndrome (RDS) 41%, and cardiac (C) 29%. Survival was overall 57%, CDH 47%, MA 88%, PH 75%, RDS 57%, and C 52%. There were no differences in survival between CT and non-CT patients compared overall, or by diagnosis, or by age <30days, or by diagnosis and age <30days. Multivariate analysis and propensity score matching for all ages, or <30days of age by diagnosis showed no difference in survival between CT and non-CT patients.

CONCLUSION

Analysis of KID with correlative propensity score matching demonstrates no increased mortality in pediatric ECMO patients requiring CT placement.

Suction on chest drains following lung resection: evidence and practice are not aligned

OBJECTIVES

A best evidence topic in Interactive CardioVascular and Thoracic Surgery (2006) looked at application of suction to chest drains following pulmonary lobectomy. After screening 391 papers, the authors analysed six studies (five randomized controlled trials [RCTs]) and found no evidence in favour of postoperative suction in terms of air leak duration, time to chest drain removal or length of stay. Indeed, suction was found to be detrimental in four studies. We sought to determine whether clinical practice is consistent with published evidence by surveying thoracic units nationally and performing a meta-analysis of current best evidence.

METHODS

We systematically searched MEDLINE, EMBASE and CENTRAL for RCTs, comparing outcomes with and without application of suction to chest drains after lung surgery. A meta-analysis was performed using RevMan(©) software. A questionnaire concerning chest drain management and suction use was emailed to a clinical representative in every thoracic unit.

RESULTS

Eight RCTs, published 2001-13, with 31-500 participants, were suitable for meta-analysis. Suction prolonged length of stay (weighted mean difference [WMD] 1.74 days; 95% confidence interval [CI] 1.17-2.30), chest tube duration (WMD 1.77 days; 95% CI 1.47-2.07) and air leak duration (WMD 1.47 days; 95% CI 1.45-2.03). There was no difference in occurrence of prolonged air leak. Suction was associated with fewer instances of postoperative pneumothorax. Twenty-five of 39 thoracic units responded to the national survey. Suction is routinely used by all surgeons in 11 units, not by any surgeon in 5 and by some surgeons in 9. Of the 91 surgeons represented, 62 (68%) routinely used suction. Electronic drains are used in 15 units, 10 of which use them routinely.

CONCLUSIONS

Application of suction to chest drains following non-pneumonectomy lung resection is common practice. Suction has an effect in hastening the removal of air and fluid in clinical experience but a policy of suction after lung resection has not been shown to offer improved clinical outcomes. Clinical practice is not aligned with Level 1a evidence.

Is the trocar technique for tube thoracostomy safe in the current era?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was, 'in adult patients who require a tube thoracostomy, is the trocar technique comparable to blunt dissection in terms of rate of tube malposition or complications?' Altogether more than 258 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. The articles included two retrospective reviews, three prospective observational studies and two prospective randomized studies. Of these, four papers concluded that the trocar technique was associated with a significantly higher rate of tube malposition and complications. One retrospective review found that the rate of tube malposition was similar in both groups; however, the trocar technique was abandoned due to the occurrence of severe complications like lung and stomach injury. Another study found that blunt dissection into the pleural space followed by the use of a trocar to direct the chest tube was as safe as and even more effective than blunt dissection alone. A randomized prospective study in cadavers comparing blunt vs sharp tip trocars reported that the use of blunt tip trocars resulted in less complications. We conclude that the trocar technique for chest tube placement should be avoided in adult patients as it is associated with a higher incidence of malposition and complications. The blunt dissection technique with digital exploration of the pleural cavity prior to chest tube placement is the safest technique and should be considered standard practice.

Iatrogenic Perforation of the Left Ventricle during Insertion of a Chest Drain

Chest draining is a common procedure for treating pleural effusion. Perforation of the heart is a rare often fatal complication of chest drain insertion. We report a case of a 76-year-old female patient suffering from congestive heart failure. At presentation, unilateral opacity of the left chest observed on a chest X-ray was interpreted as massive pleural effusion, so an attempt was made to drain the left pleural space. Malposition of the chest drain was suspected because blood was draining in a pulsatile way from the catheter. Computed tomography revealed perforation of the left ventricle. Mini-thoracotomy was performed and the drain extracted successfully.