Timing of Chest Tube Removal Following Adult Cardiac Surgery: A Cluster Randomized Controlled Trial

OBJECTIVES

Early chest tube removal following cardiac surgery may be associated with an increased risk of pleural or pericardial effusions following cardiac surgery. This study compares the effects of two fast-track chest tube removal protocols regarding the risk of pleural or pericardial effusions, requirement of opioids, respiratory function, and postoperative complications.

DESIGN

Prospective non-blinded cluster-randomized study with alternating chest tube removal protocol in adult patients undergoing elective cardiac surgery. Monthly changing allocation to scheduled chest tube removal on the day of surgery (Day 0) versus removal on the 1st postoperative day (Day 1) provided no air leakage and output < 200 mL within the last four hours.

RESULTS

A total of 527 patients were included in the study from September 1st 2020 until October 29th 2021 and randomly allocated to chest tube removal at day 0 (n = 255), and day 1 (n = 272). More than every fourth patient required drainage for pleural effusion with no significant difference between the groups. Earlier removal of chest tubes did not reduce requirement of analgesics, improve early respiratory function, or reduce postoperative complications. The study was halted for futility after halfway interim analysis showed insufficient promise of any treatment benefit.

CONCLUSION

Fast-track protocols with chest tube removal within the first 24 h after cardiac surgery may be associated a high rate of pleural effusions.

Enhanced recovery after surgery program focusing on chest tube management improves surgical recovery after video-assisted thoracoscopic surgery

OBJECTIVE

Chest drainage is a standard procedure in thoracoscopic surgery for lung cancer. However, chest tube placement may deteriorate the ventilation capacity and increase difficulty of postoperative management of patients. The study investigated on the effects of enhanced recovery after surgery (ERAS) program focusing on chest tube management on surgical recovery of lung cancer patients.

METHODS

The study population consisted of 60 patients undergoing video-assisted thoracoscopic surgery (VATS) after implementation of ERAS program and another group of 60 patients undergoing VATS before implementation of ERAS program.

RESULTS

The mean time of first food intake was 12.9 h required for the ERAS group, which was significantly shorter than 18.4 h required for the control group (p < 0.0001). The mean time of out-of-bed activity was 14.2 h taken for the ERAS group, which was notably shorter than 22.8 h taken for the control group (p < 0.0001). The duration of chest tube placement was 68.6 h in the ERAS group, which was remarkably shorter than 92.8 h in the control group (p < 0.0001). The rate overall postoperative complications were notably lower in the ERAS group than in the control group (p = 0.018). The visual analogue score (VAS) scores on the second postoperative day exhibited significant differences between the ERAS group and the control group (p = 0.017). The patients in the ERAS group had a shorter hospitalization stay than those in the control group (p < 0.0001).

CONCLUSION

The study suggests the ERAS program focusing on chest tube management could improve surgical recovery, remove patient chest tube earlier, and relieve patient pain after VATS.

Hybrid (Digital/Water Seal) Chest Drainage System - An Innovative Device for Patients with Anticipated Air Leaks

BACKGROUND

To date, several chest drainage systems are available, such as digital drainage systems (DDS) and traditional systems with continuous suction or water seal. However, none of these systems were yet shown to be favorable in the treatment of complex situations such as persistent air leaks or residual spaces. We present in-vitro as well as clinical data of a novel hybrid drainage system consisting of an optimized digital drainage system (ODDS) and an underwater seal drainage system (UWSD).

METHODS

For in-vitro analysis, a DDS and an ODDS were connected to a pleural cavity simulator. Different air leaks were produced and data on intrapleural pressure and air flow were analyzed. Furthermore, we tested the hybrid drainage system in 10 patients with potential air leaks after pulmonary surgery.

RESULTS

In in-vitro analysis, we could show, that with advanced pump technology, pressure fluctuations caused by the drainage system when trying to maintain a set pressure level in patients with airleaks were much smaller when using an ODDS and could even be eliminated when using a fluid collection canister with sufficient buffer capacity. This minimized air leak boosts caused by the drainage system. Optimizing the auto-pressure regulation algorithms also led to a reduced airflow through the fistula and promoted rest. Switching to a passive UWSD also reduced the amount of airflow. Clinical application of the hybrid drainage system yielded promising results.

CONCLUSION

The novel hybrid drainage system shows promising results in the treatment of patients with complex clinical situations such as persistent air leaks.

The prevalence of pneumothorax in human immunodeficiency virus patients. A single center study

OBJECTIVES

To assess the prevalence, risk factors, and associated complications of pneumothorax that are present in patients with human immunodeficiency virus (HIV) at our institution and to provide an updated local study addressing the association between pneumothorax and HIV.

METHODS

This retrospective cohort study examined 161 patients who were admitted with a diagnosis of HIV from June 2017 to May 2022. They were divided into 2 groups depending on the presence of pneumothorax during their stay. Multiple variables were studied, including age, gender, tuberculosis infection, pneumocystis jiroveci pneumonia (PJP)infection, bacterial pneumonia, and pneumothorax type and treatment course.

RESULTS

There were 11 patients diagnosed with pneumothorax (prevalence rate: 6.8%). Bacterial lung infection was found in 9 (81.8%) of these patients, while fungal infection was found in 6 (54.5%) (p<0.001, 0.010). The MTB was found in 3 (27.3%) patients (p=0.728), while none were infected with PJP. Intercostal tube insertion was attempted in 9 (81.8%) patients, the mean duration of tube stay was 39.3±30.7 days, and the mortality rate was 72.7% (p=0.007).

CONCLUSION

Pneumothorax in patients with HIV is a manifestation of the progression of the disease and its poor outcome. It has a complicated treatment course and a high mortality rate.

Evaluating the safety of intraprocedural chest tube removal during medical thoracoscopy

BACKGROUND

Medical Thoracoscopy (MT) is a diagnostic procedure during which after accessing the pleural space the patient's negative-pressure inspiratory efforts draw atmospheric air into the pleural cavity, which creates a space to work in. At the end of the procedure this air must be evacuated via a chest tube, which is typically removed in the post-anesthesia care unit (PACU). We hypothesized that its removal intra-operatively is safe and may lead to lesser post-operative pain in comparison to its removal in the PACU.

METHODS

A retrospective review was conducted of all the MT with intraprocedural chest tube removal done between 2019 to 2023 in adult patients in a single center in New York, NY by interventional pulmonology.

RESULTS

A total of 100 MT cases were identified in which the chest tube was removed intra-operatively. Seventy-seven percent of cases were performed as outpatient and all these patients were discharged on the same day. Post procedure ex-vacuo pneumothorax was present in 42% of cases. Sixty-five percent of cases had some post-procedure subcutaneous emphysema, none reported any complaint of this being painful, and no intervention was needed to relieve the air. Seventy-three percent required no additional analgesia in PACU. Of the 27% that required any form of analgesia, 59% required no additional analgesia beyond the first 24 h.

CONCLUSIONS

Intraprocedural CT removal for MT is safe and may decrease utilization of additional analgesia post procedure. Further prospective studies are necessary to validate these conclusions.

The value of chest radiography after chest tube removal in nonventilated trauma patients: A post hoc analysis of a multicenter prospective cohort study

BACKGROUND

Chest tubes are commonly placed in trauma care to treat life-threatening intrathoracic injuries by evacuating blood or air from the pleural cavity. Currently, it is common practice to routinely obtain chest radiographs between 1 to 8 hours after chest tube removal, while the necessity of it has been questioned. This study describes the "ins-and-outs" of chest tubes and evaluates the value of routine postremoval chest radiography in nonventilated trauma patients.

METHODS

A post hoc analysis of a multicenter observational prospective cohort study was performed in blunt chest trauma patients admitted with multiple rib fractures to two level 1 trauma centers between January 2018 and March 2021 and treated with one or more chest tubes. Exclusion criteria were mechanical ventilation during chest tube removal, missing reports of postremoval chest radiography, transfer to another hospital, or mortality before chest tube removal. Descriptive analyses were performed to calculate the number of findings on postremoval chest radiographs and reinterventions.

RESULTS

A total of 207 patients were included for analysis of whom 14 underwent bilateral chest tube placement, resulting in 221 chest tube removals investigated in this study. The mean ± SD age was 58 ± 17 years, 71% were male, 73% had American Society of Anesthesiologists scores of 1 or 2, and the median Injury Severity Score was 19 (interquartile range, 14-29). In 68 of 221 chest tube removals (31%), postremoval chest radiography showed increased or recurrent intrathoracic pathology (i.e., 13% pneumothorax, 18% pleural fluid, and 8% atelectasis). Only two (3%) of these patients underwent a same-day reintervention based on these findings, of whom one had signs or symptoms of recurrent pathology and one was asymptomatic.

CONCLUSION

It seems safe to omit routine use of postremoval chest radiography in nonventilated blunt chest trauma patients and to selectively use imaging in those patients presenting with clinical signs or symptoms after chest tube removal.

LEVEL OF EVIDENCE

Diagnostic Tests/Criteria; Level IV.

Zero-leak prediction during major lung resection aiming for minimal chest drainage duration: a retrospective analysis

BACKGROUND

Early chest tube removal should be considered to enhance recovery after surgery. The current study aimed to provide a predictive algorithm for air leak episodes (ALE) and to create a knowledge base for early chest tube removal.

METHODS

This retrospective study enrolled patients who underwent thoracoscopic anatomical pulmonary resections in our unit. We defined ALE as any airflow ≥ 10 mL/min recorded in the follow-up charts based on the digital thoracic drainage device. Multivariate regression analysis was used to control for preoperative and intraoperative confounding factors. The ALE prediction algorithm was constructed by combining an additive ALE risk-scoring system using the coefficients of the significant predictive factors with the intraoperative water-sealing test.

RESULTS

In 485 consecutive thoracoscopic major pulmonary resections, ALE developed in 209 (43%) patients. Statistically significant ALE-associated preoperative factors included male sex, lower body mass index, radiologically evident emphysema, lobectomy, and upper lobe surgery. Significant ALE-associated intraoperative factors were incomplete fissure and pleural adhesion. The ALE risk scoring demonstrated an average area under the receiver operating characteristic curve of 0.72 in the fivefold cross-validation test. The ALE prediction algorithm correctly predicted ALE-absent patients at a negative predictive value of 80%.

CONCLUSIONS

The algorithm may promote the optimization of the chest tube-dwelling duration by identifying potential ALE-absent patients for accelerated tube removal.

Chest tube removal at different gas flows in prolonged air leak: a randomized non-inferiority trial

OBJECTIVES

To evaluate the safety and feasibility of removing drainage tubes at larger size of air leak in patients with prolonged air leak after pulmonary surgery.

METHODS

Ninety-five patients who underwent pulmonary surgery with prolonged air leak in our centre were enrolled in this randomized controlled, single-centre, non-inferiority study. The drainage tube was clamped with a stable size of air leak observed over the last 6 h, which was quantified by gas flow rate using the digital drainage system. The control group (n = 48) and the study group (n = 46) had their drainage tube clamped at 0-20 ml/min and 60-80 ml/min, respectively. We continuously monitored clinical symptoms, conducted imaging and laboratory examinations, and decided whether to reopen the drainage tube.

RESULTS

The reopening rate in the study group was not lower than that in the control group (2.08% vs 6.52%, P > 0.05). The absolute difference in reopening rate was 4.44% (95% confidence interval -0.038 to 0.126), with an upper limit of 12.6% below the non-inferiority margin (15%). There were significant differences in the length of stay [16.5 (13-24.75) vs 13.5 (12-19.25), P = 0.017] and the duration of drainage [12 (9.25-18.50) vs 10 (8-12.25), P = 0.007] between the control and study groups. No notable differences were observed in chest X-ray results 14 days after discharge or in the readmission rate.

CONCLUSIONS

For patients with prolonged air leak, removing drainage tubes at larger size of air leak demonstrated similar safety compared to smaller size of air leak, and can shorten both length of stay and drainage duration.

CLINICAL TRIAL REGISTRATION NUMBER

Name of registry: Gas flow threshold for safe removal of chest drainage in patients with alveolar-pleural fistula prolonged air leak after pulmonary surgery. Registration number: ChiCTR2200067120. URL: https://www.chictr.org.cn/.

Effects of virtual reality on chest tube removal pain management in patients undergoing coronary artery bypass grafting: a randomized clinical trial

The pain associated with chest tube removal (CTR) is one of the significant complications of cardiac surgery. The management of this pain is recognized as a vital component of nursing care. The application of distraction techniques using virtual reality (VR) is an effective and straightforward non-pharmacological approach to alleviate pain. This study aimed to determine the impact of VR technology on the management of pain caused by CTR following coronary artery bypass grafting (CABG). This randomized clinical trial was conducted on 70 patients undergoing CABG at Imam Reza and Qaem hospitals in Mashhad, Iran, in 2020. The patients were randomly divided into two groups of 35. For the intervention group, a 360-degree video was played using VR glasses 5 min before the CTR procedure. The pain intensity was measured before, immediately after, and 15 min after CTR, using the Visual Analogue Scale. Also, the Depression Anxiety and Stress Scale-21 (DASS-21), and the Rhoten Fatigue Scale (RFS) were used to evaluate intervention and control groups before the CTR procedure. The collected data was analyzed using statistical tests, such as Chi-square, independent t-test, and Mann-Whitney test. The patients were homogeneous in terms of stress, anxiety, and fatigue levels before CTR, and they did not show any significant differences (P > 0.05). The average pain intensity score of patients in the intervention group significantly decreased immediately and 15 min after CTR, compared to the control group (P < 0.001). Given the positive impact of VR distraction on the severity of pain associated with CTR in patients undergoing CABG, this technique can serve as an effective, accessible, and cost-efficient non-pharmacological approach for managing pain in these patients.Trial registration: This study was registered in the Iranian Registry of Clinical Trials (code: IRCT20190708044147N1; approval date, 08/26/2019).

[Diagnosis and management of idiopathic spontaneous pneumothorax in adolescents]

INTRODUCTION

Due to the absence of consensual definition and agreed-upon pediatric treatment, pneumothorax (PNO) in children and adolescents often remains difficult to properly apprehend.

STATE OF THE ART

While initial diagnostic suspicion is clinical, confirmation necessitates chest imaging, and lung ultrasound has become increasingly prevalent, often at the expense of chest radiography. The goal of treatment is twofold, on the one hand to a fully re-expand the lungs, and on the other hand to forestall PNO recurrence. Depending on PNO severity and clinical tolerance, it may be advisable to envision conservative management, oxygen supplementation, needle exsufflation, or chest tube drainage.

PERSPECTIVES

In order to harmonize clinical practices, guidelines for the precise definition and graduated management of PNO in children and adolescents are highly advisable.

CONCLUSIONS

Idiopathic spontaneous PNO frequently occurs in teenage populations, and its likewise frequent recurrence is not satisfactorily predicted by chest CT findings. It is of paramount importance that patients be fully informed of the risk of recurrence.

Teaching Chest Tube Insertion by Blended Learning: A Multi-Dimensional Analysis

BACKGROUND

Emerging technologies are being incorporated in surgical education. The use of such technology should be supported by evidence that the technology neither distracts nor overloads the learner and is easy to use. To teach chest tube insertion, we developed an e-learning module, as part of a blended learning program delivered prior to in-person hands-on simulation. This pilot study was aimed to assess learning effectiveness of this blended learning, and cognitive load and the usability of e-learning.

METHODS

The interactive e-learning module with multimedia content was created following learning design principles. In advance of the standard simulation, 13 first-year surgical residents were randomized into two groups: 7 received the e-learning module and online reading materials (e-learning group); 6 received only the online reading materials (controls). Knowledge was evaluated by pre-and post-tests; technical performance was assessed using a Global Rating Scale by blinded assessors. Cognitive load and usability were evaluated using rating scales.

RESULTS

The e-learning group showed significant improvement from baseline in knowledge (P = .047), while controls did not (P = .500). For technical skill, 100% of residents in the e-learning group reached a predetermined proficiency level vs 60% of controls (P = .06). The addition of e-learning was associated with lower extrinsic and greater germane cognitive load (P = .04, .03, respectively). Usability was evaluated highly by all participants in e-learning group.

CONCLUSION

Interactive e-learning added to hands-on simulation led to improved learning and desired cognitive load and usability. This approach should be evaluated in teaching of other procedural skills.

Effectiveness of Cold Therapy for Pain and Anxiety Associated with Chest Tube Removal: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

To assess the effectiveness of cold therapy for pain and anxiety associated with chest tube removal.

DESIGN

A Systematic review and meta-analysis of randomized controlled trials.

DATA SOURCES

Articles were searched from Cochrane Library, PubMed, Embase, CINAHL, ProQuest, Airiti Library, China National Knowledge Infrastructure, and the National Digital Library of Theses and Dissertations in Taiwan.

REVIEW/ANALYSIS METHODS

Eight electronic databases were searched from inception to August 20, 2022. The Cochrane Risk of Bias 2.0 tool was used to assess the quality of the included studies. Using a random-effects model, we calculated Hedges' g and its associated confidence interval to evaluate the effects of cold therapy. Cochrane's Q test and an I2 test were used to detect heterogeneity, and moderator and meta-regression analyses were conducted to explore possible sources of heterogeneity. Publication bias was assessed using a funnel plot, Egger's test, and trim-and-fill analysis.

RESULTS

We examined 24 trials involving 1,821 patients. Cold therapy significantly reduced pain during and after chest tube removal as well as anxiety after chest tube removal (Hedges' g: -1.28, -1.27, and -1.80, respectively). Additionally, the effect size of cold therapy for reducing anxiety after chest tube removal was significantly and positively associated with that of cold therapy for reducing pain after chest tube removal.

CONCLUSIONS

Cold therapy can reduce pain and anxiety associated with chest tube removal.

Training, experience, and perceptions of chest tube insertion by higher speciality trainees: implications for training, patient safety, and service delivery

BACKGROUND

Seldinger Chest Tube Insertion (CTI) is a high acuity low occurrence procedure and remains a core capability for UK physician higher speciality trainee's (HST). A multitude of factors have emerged which may affect the opportunity of generalists to perform CTI. In view of which, this paper sought to establish the current experiences, attitudes, training, and knowledge of medical HST performing Seldinger CTI in acute care hospitals in the Peninsula deanery.

METHODS

A Scoping review was performed to establish the UK medical HST experience of adult seldinger CTI. Synonymous terms for CTI training were searched across Cochrane, ERIC, Pubmed and British education index databases. Following which, a regional survey was constructed and completed by HST and pleural consultants from five hospitals within the Peninsula deanery between April-July 2022. Data collected included participants demographics, attitudes, training, experience, and clinical knowledge. Outcomes were collated and comparisons made across groups using SPSS. A p-value of < 0.05 was defined as significant.

RESULTS

The scoping review returned six papers. Salient findings included low self-reported procedural confidence levels, poor interventional selection for patient cases, inadequate site selection for CTI and 1 paper reported only 25% of respondents able to achieve 5-10 CTI annually. However, all papers were limited by including grades other than HST in their responses. The regional survey was completed by 87 HST (12 respiratory, 63 non-respiratory medical HST and 12 intensivists/anaesthetists HST). An additional seven questionnaires were completed by pleural consultants. Respiratory HSTs performed significantly more Seldinger CTI than general and ICM/anaesthetic registrars (p < 0.05). The percentage of HST able to achieve a self-imposed annual CTI number were 81.8, 12.9 and 41.7% respectively. Self-reported transthoracic ultrasound competence was 100, 8 and 58% respectively (p < 0.001). The approach to clinical management significantly differed with national guidance with pleural consultants showing an agreement of 89%, respiratory HST 75%, general HST 52% and ICM/anaesthetic HST 54% (p = 0.002).

CONCLUSION

Compared to respiratory trainees, non-respiratory trainees perform lower numbers of Seldinger CTI, with lower confidence levels, limited knowledge, and a reduced perceived relevance of the skill set. This represents a significant training and service challenge, with notable patient safety implications.

Chest X-Ray Remains a Vital Component Prior to Tube Thoracostomy

INTRODUCTION

The identification and treatment of traumatic pneumothorax (PTX) has long been a focus of bedside imaging in the trauma patient. While the emergence of bedside ultrasound (BUS) provides an opportunity for earlier detection, the need for tube thoracostomy (TT) based on bedside imaging, including BUS and supine AP chest X-ray (CXR) is less established in the medical literature.

METHODS

Retrospective data from 2017 to 2020 were collected of all adult trauma activations at a level 1 rural trauma facility. Every adult patient included in this study received a CXR and BUS (eFast) upon arrival. The need for TT was determined by the emergency medicine attending or the trauma surgery attending evaluating the patient. McNemar's chi-squared test and conditional logistic regression analysis were performed comparing BUS, CXR, and the combination of BUS and CXR findings for the need for TT. Subgroup analyses were performed comparing BUS, CXR, and the combination of BUS and CXR for the detection of PTX compared to CT scan.

RESULTS

Of the 12,244 patients who underwent trauma activation during this timeframe, 602 were included in the study. 74.9% were males with an age range of 36-63 years. Of the 602 patients, 210 received TT. Positive PTX was recorded with BUS in 128 (21%) patients with 16 false negatives (FNs) and 98 false positives (FPs), 100 (17%) PTX were identified with CXR with 114 FNs and 4 FPs, and 72 (11.9%) were noted on both CXR and BUS with 140 FNs and 2 FPs. The odds ratio of TT placement was 22 times with positive BUS alone (P < .0001, 95% CI: 10.9-43.47), 47 times with positive CXR alone (P < .0001, 95% CI: 16.99-127.5), and 70 times with both positive CXR and BUS (P < .0001, 95% CI: 17.08-288.4).

CONCLUSION

A positive finding of PTX on BUS combined with CXR is more indicative of the need for TT in the trauma patient when compared with BUS or CXR alone.

DraiNet: AI-driven decision support in pneumothorax and pleural effusion management

OBJECTIVE

This study presents DraiNet, a deep learning model developed to detect pneumothorax and pleural effusion in pediatric patients and aid in assessing the necessity for tube thoracostomy. The primary goal is to utilize DraiNet as a decision support tool to enhance clinical decision-making in the management of these conditions.

METHODS

DraiNet was trained on a diverse dataset of pediatric CT scans, carefully annotated by experienced surgeons. The model incorporated advanced object detection techniques and underwent evaluation using standard metrics, such as mean Average Precision (mAP), to assess its performance.

RESULTS

DraiNet achieved an impressive mAP score of 0.964, demonstrating high accuracy in detecting and precisely localizing abnormalities associated with pneumothorax and pleural effusion. The model's precision and recall further confirmed its ability to effectively predict positive cases.

CONCLUSION

The integration of DraiNet as an AI-driven decision support system marks a significant advancement in pediatric healthcare. By combining deep learning algorithms with clinical expertise, DraiNet provides a valuable tool for non-surgical teams and emergency room doctors, aiding them in making informed decisions about surgical interventions. With its remarkable mAP score of 0.964, DraiNet has the potential to enhance patient outcomes and optimize the management of critical conditions, including pneumothorax and pleural effusion.

Machine-Learned Algorithms to Predict the Risk of Pneumothorax Requiring Chest Tube Placement after Lung Biopsy

PURPOSE

To develop a machine-learned algorithm to predict the risk of postlung biopsy pneumothorax requiring chest tube placement (CTP) to facilitate preprocedural decision making, optimize patient care, and improve resource allocation.

MATERIALS AND METHODS

This retrospective study collected clinical and imaging features of biopsy samples obtained from patients with lung nodule biopsy and included information from 59 procedures resulting in pneumothorax requiring CTP and randomly selected 67 procedures without CTP (convenience sample). The data were divided into 70 and 30 as training and testing sets, respectively. Conventional machine-learned binary classifiers were explored with preprocedural imaging and clinical data as input features and CTP as the output.

RESULTS

There was no single pathognomonic imaging or predictive clinical feature. For the independent test set under the high-specificity mode, a decision tree, logistic regression, and Naïve Bayes classifier achieved accuracies of identifying CTP at 0.79, 0.93, and 0.89 and area under receiver operating curves (AUROCs) of 0.68, 0.76, and 0.82, respectively. Under high-sensitivity mode, a decision tree, logistic regression, and Naïve Bayes achieved accuracies of identifying CTP of 0.60, 0.45, and 0.60 with AUROCs of 0.71, 0.81, and 0.82, respectively. High importance features included lesion character, chronic obstructive pulmonary disease, lesion depth, and age. A coarse decision tree requiring 4 inputs achieved comparable performance as other methods and previous machine learning prediction studies.

CONCLUSIONS

The results support the possibility of predicting pneumothorax requiring CTP after biopsy based on an automated decision support, reliant on readily available preprocedural information.

Thoracostomy tube withdrawal during latter phases of expiration or inspiration: a systematic review and meta-analysis

PURPOSE

In patients with thoracic injuries, tube thoracostomy is routinely employed. There is disagreement over which manner of tube withdrawal is best, the latter phases of expiration or inspiration. Considering several earlier investigations' inconsistent findings, their comparative effectiveness is still up for debate. In light of this, we carried out a systematic analysis of studies contrasting the withdrawal of thoracostomy tubes during the latter stages of expiration versus inspiration for traumatic chest injuries. Analyzed outcomes are recurrent pneumothoraces, reinsertion of the thoracostomy tube, and hospital stay.

METHODS

We looked for papers comparing the withdrawal of the thoracostomy tube during the last stages of expiration and inspiration for the management of thoracic injuries on Embase, Pubmed, Cochrane Library and Google Scholar. Review Manager was used to determine mean differences (MD) and risk ratios (RR) using a 95% confidence interval (CI).

RESULTS

The primary outcomes showed no significant difference between the inspiration and expiration groups: recurrent pneumothorax (RR 1.27, 95% CI 0.83-1.93, P 0.28) and thoracostomy tube reinsertion (OR: 1.84, CI 0.50-6.86, P 0.36, I2 5%). However, the duration of hospital stay was significantly lower in patients in whom the thoracostomy tube was removed at the end of inspiration (RR 1.8, 95% CI 1.49-2.11, P < 0.00001, I2 0%). The implications of these findings warrant cautious interpretation, accounting for potential confounding factors and inherent limitations that may shape their significance.

CONCLUSION

The thoracostomy tube can be removed during both the end-expiratory and end-inspiratory stages of respiration with no appreciable difference. Nevertheless, caution should be exercised when ascertaining the implications of these findings, taking into account the potential limitations and confounding variables that may exert influence upon the outcomes.

Use of a Digital Air Leak Detection Device to Decrease Chest Tube Duration

BACKGROUND

The aim of this evidence-based practice project was to determine if a digital air leak detection device could speed the identification of chest tube air leak cessation in patients after pulmonary lobectomy. Staff members assessing air leaks have varying levels of expertise, and the digital device is a limited resource in the study institution. A chest tube management algorithm is necessary to standardize care and determine which patients are most likely to benefit.

IMPLEMENTATION

Twenty-five consecutive patients who underwent pulmonary lobectomy during the study period and continued to have a chest tube air leak on postoperative day 3 were monitored with digital air leak detection devices. The Mann-Whitney U test was used to compare chest tube duration and hospital length of stay between patients with digital devices and 259 patients who had traditional analog air leak detection devices (historical data from the departmental database over the previous 2 years).

EVALUATION

Median chest tube duration and hospital stay were 1 day less in patients with digital devices than in those with traditional analog devices (P = .01 and P = .004, respectively), with a cost savings of $2659 per hospital day. Reductions in chest tube duration and length of stay aided in the development of a chest tube management algorithm.

CONCLUSIONS

Critical care nurses are valued team members who treat patients after lung resections. Digital air leak detection devices can help them assess air leaks more accurately, benefiting the patients in their care.

Is there a common definition for massive pleurisy?

The concept of massive pleurisy (MP) is frequently used to emphasize the significance of the amount of pleural effusion. However, there are significant disagreements about it due to the lack of a universal definition for MP. In our study, we sought to elucidate these distinctions. We employed a questionnaire comprised of visual and true/false sections. In the visual section, participants were shown real-time lung radiographs and schematic drawings and asked which ones were MP. On the other hand, suggestions regarding diagnosis, treatment, and consultations for MP were questionnaired. The study was comprised of 150 physicians from four distinct centers. On true/false and radiograph questions, physicians from the same branch exhibited differences of up to 50% (p < 0.05). On the level question, each branch involved reached a consensus (p = 0.003). In questions 3, 4, and 5, which also contained a true-false section, the branches gave varying responses, with the exception of the opinion that tube thoracostomy is unquestionably indicated in MP (p < 0.05). Establishing a common language for MP is crucial for clinician collaboration and appropriate patient management. Our study elucidates the divergences of opinion between branches and highlights the need for a unified definition.

Conservative and Surgical Modalities in the Management of Pediatric Parapneumonic Effusion and Empyema: A Living Systematic Review and Network Meta-Analysis

BACKGROUND

The optimal treatment for community-acquired childhood pneumonia complicated by empyema remains unclear.

RESEARCH QUESTION

In children with parapneumonic effusion or empyema, do hospital length of stay and other key clinical outcomes differ according to the treatment modality used?

STUDY DESIGN AND METHODS

A living systematic review of randomized controlled trials (RCTs) was conducted by searching the Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Health Sciences Literature, Ovid MEDLINE, and Web of Science Core Collection databases. Eligible RCTs included patients aged < 18 years and compared two of the following treatment modalities: antibiotics alone, chest tube insertion with or without fibrinolytics, video-assisted thoracoscopic surgery (VATS), and decortication via thoracotomy. A network meta-analysis was performed to evaluate treatment effects on hospital length of stay (LOS), the primary outcome.

RESULTS

Eleven trials including a total of 590 patients were selected for the network meta-analysis. Compared with a chest tube alone, a chest tube with fibrinolytics, thoracotomy, and VATS were all associated with shorter LOS, with a mean difference of 5.05 days (95% CI, 2.46-7.64), 6.33 days (95% CI, 3.17-9.50), and 5.86 days (95% CI, 3.38-8.35), respectively. No substantial differences in LOS were observed between the latter three interventions. None of the 11 RCTs compared antibiotics alone vs other types of treatment. Most trials reported peri-procedural complications and the need for reintervention, but the descriptions differed significantly between trials, preventing meta-analysis. In trials reporting health care-associated costs, fibrinolytics had cost advantages compared with VATS. Short- and long-term morbidity and mortality were very low, regardless of the treatment modality.

INTERPRETATION

The results of this network meta-analysis showed that a chest tube alone was associated with a longer LOS compared with other treatment modalities. The lower cost associated with a chest tube plus fibrinolytics warrants consideration when choosing between treatment options, given similar LOS and clinical outcomes compared with the other modalities.

Bioadhesive patch as a parenchymal sparing treatment of acute traumatic pulmonary air leaks

INTRODUCTION

Traumatic pulmonary injuries are common in chest trauma. Persistent air leaks occur in up to 46% of patients depending on injury severity. Prolonged leaks are associated with increased morbidity and cost. Prior work from our first-generation pectin patches successfully sealed pulmonary leaks in a cadaveric swine model. We now test the next-generation pectin patch against wedge resection in the management of air leaks in anesthetized swine.

METHODS

A continuous air leak of 10% to 20% percent was created to the anterior surface of the lung in intubated and sedated swine. Animals were treated with a two-ply pectin patch or stapled wedge resection (SW). Tidal volumes (TVs) were recorded preinjury and postinjury. Following repair, TVs were recorded, a chest tube was placed, and animals were observed for presence air leak at closure and for an additional 90 minutes while on positive pressure ventilation. Mann-Whitney U test and Fisher's exact test used to compare continuous and categorical data between groups.

RESULTS

Thirty-one animals underwent either SW (15) or pectin patch repair (PPR, 16). Baseline characteristics were similar between animals excepting baseline TV (SW, 10.3 mL/kg vs. PPR, 10.9 mL/kg; p = 0.03). There was no difference between groups for severity of injury based on percent of TV loss (SW, 15% vs. PPR, 14%; p = 0.5). There was no difference in TV between groups following repair (SW, 10.2 mL/kg vs. PPR, 10.2 mL/kg; p = 1) or at the end of observation (SW, 9.8 mL/kg vs. PPR, 10.2 mL/kg; p = 0.4). One-chamber intermittent air leaks were observed in three of the PPR animals, versus one in the SW group ( p = 0.6).

CONCLUSION

Pectin patches effectively sealed the lung following injury and were noninferior when compared with wedge resection for the management of acute traumatic air leaks. Pectin patches may offer a parenchymal sparing option for managing such injuries, although studies evaluating biodurability are needed.

The impact of suction addition to simple water seal on the outcomes after pulmonary surgery: A meta-analysis

BACKGROUND

Chest tube drainage during pulmonary surgery is fundamental to removing air and fluid, as well as for lung re-expansion. However, the advantages of adding external suction to the water seal are under debate.

OBJECTIVES

The aim of the study was to conduct a meta-analysis in order to assess the effects of adding suction to a simple water seal on the outcomes of lung surgery.

MATERIAL AND METHODS

A search of the literature up to November 2021 found 14 studies with 2449 lung surgery patients. Of these patients, 1092 received suction drainage and 1357 received a simple water-seal drainage. The studies reported the effects of adding suction to a simple water seal on postoperative outcomes after lung surgery. A randomor fixed-effect model determined the odds ratio (OR) or mean difference (MD) with 95% confidence intervals (95% CIs) to compare the outcomes.

RESULTS

In patients undergoing lung surgery, suction resulted in a substantially longer chest tube duration (MD = 0.74, 95% CI: 0.90-1.40, p = 0.03, Z = 2.21) and a smaller postoperative pneumothorax (OR = 0.27, 95% CI: 0.13-0.59, p = 0.02, Z = 2.24) than a simple water seal. However, no differences existed in prolonged air leak (p = 0.91, Z = 0.12), air leak duration (p = 0.28, Z = 1.07) or length of hospital stay (p = 0.23, Z = 1.2) between the 2 approaches.

CONCLUSION

Suction led to considerably longer chest tube duration and lower postoperative pneumothorax, but no significant difference in sustained air leak, air leak duration or length of hospital stay was observed compared to a simple water seal in patients undergoing pulmonary surgery. Further research is needed to validate these findings and increase confidence, particularly regarding the postoperative pneumothorax results.

Conventional and digital pleural drainage systems - advantages and disadvantages

INTRODUCTION

Pleural cavity drainage is a crucial component of the surgical management of patients with various chest diseases. Digital drainage systems are increasingly used in contemporary thoracic surgical procedure, which is likely a result of their effectiveness in achieving early postoperative ambulation, cutting down on hospital stays and lowering costs. The vast majority of thoracic surgeons worldwide prefer digital drainage systems to traditional ones. The advantages of the former, however, are disputed by some researchers.

Unnecessity of routine chest tube drainage after patent ductus arteriosus ligation in preterm neonates

BACKGROUND

Conventionally, a chest tube drainage is placed following patent ductus arteriosus (PDA) ligation to monitor possible bleeding and drain air or effusion postoperatively. However, the necessity of chest tube drainage after thoracotomy in PDA ligation is controversial. We evaluated the feasibility and safety of omitting chest tube drainage in preterm neonates who underwent PDA ligation via thoracotomy.

METHODS

We retrospectively reviewed the medical records of 56 preterm neonates who underwent surgical ligation of PDA via thoracotomy in the neonatal intensive care unit between January 2014 and March 2022.

RESULTS

The median gestational age was 26.9 (interquartile range [IQR]: 25.9-28.8) weeks and the median body weight at birth was 895 (IQR: 795-1190) g. The median age on the day of surgery was 17.0 (IQR: 10.0-22.0) days and the median body weight on the day of surgery was 1100 (IQR: 958-1410) g. The median operative time was 44.5 (IQR: 35.5-54.0) minutes. There were no intraoperative events or procedure-related deaths. On postoperative chest radiographs, no patients had major complications, such as pneumothorax or hemothorax. Nineteen patients (34%) had minor complications of subcutaneous emphysema around the thoracotomy site. No patients required additional chest tube drainage for postoperative bleeding, pleural effusion, or progressive subcutaneous emphysema. No patients had surgical wound infections. There were seven in-hospital mortalities, which were unrelated to the surgery.

CONCLUSIONS

Omitting chest tube drainage is feasible and safe for the postoperative management of preterm neonates undergoing PDA ligation via thoracotomy.

The Impact Of Active Chest Tube Clearance Technology On Surgical Outcomes After Cardiac Surgery: An Updated Systematic Review And Meta-Analysis

OBJECTIVE

Active chest tube clearance technology (ACT) systems were introduced to improve the patency of chest tubes and to reduce the potential complications associated with inadequate mediastinal blood drainage after cardiac surgical procedures. The purpose of this study is to assess the impact of ACT on the incidence of chest tube clogging, retained blood syndromes (RBS), re-exploration for bleeding, and the incidence of postoperative atrial fibrillation (POAF) after cardiac surgical procedures.

METHODS

A database search was conducted using Medline, Embase, Cochrane Library, and Web of Science. Only articles comparing the use of ACT to conventional chest tube drainage after cardiac surgery were screened. Included articles were restricted to adult patients and English language only.

RESULTS

Nine of the 841 articles screened were included in this review. Two studies were randomized controlled trials (RCT) and seven were observational studies. Pooled estimates showed RBS, surgical re-exploration rates, and POAF were significantly less common in the ACT group.

CONCLUSION

Our meta-analysis suggests that the use of ACT may be beneficial in reducing the incidence of postoperative complications associated with inadequate drainage of mediastinal blood after cardiac surgery. However, more robust evidence is required to endorse these findings and support the routing use of ACT in clinical practice.

Update on the management of first episode primary spontaneous pneumothorax in an Australian hospital network

International guidelines and recent research favour a less interventional approach to primary spontaneous pneumothorax (PSP). A retrospective clinical audit of 68 first-episode PSP was undertaken at a major tertiary teaching hospital network in Melbourne, Australia, found that most patients presenting with a moderate to large pneumothorax received initial intercostal catheter insertion (56%), though many (81%) would have met criteria for consideration of conservative management. The results suggest continued deviation from clinical guidelines in the management of PSP.

Evaluation and Management of Primary Spontaneous Pneumothorax in Adolescents and Young Adults: A Systematic Review From the APSA Outcomes & Evidence-Based Practice Committee

INTRODUCTION

Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee performed a systematic review of the literature to develop evidence-based recommendations.

METHODS

Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL, Elsevier Scopus, and Wiley Cochrane Central Register of Controlled Trials databases were queried for literature related to spontaneous pneumothorax between January 1, 1990, and December 31, 2020, addressing (1) initial management, (2) advanced imaging, (3) timing of surgery, (4) operative technique, (5) management of contralateral side, and (6) management of recurrence. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed.

RESULTS

Seventy-nine manuscripts were included. Initial management of adolescent and young adult primary spontaneous pneumothorax should be guided by symptoms and can include observation, aspiration, or tube thoracostomy. There is no evidence of benefit for cross-sectional imaging. Patients with ongoing air leak may benefit from early operative intervention within 24-48 h. A video-assisted thoracoscopic surgery (VATS) approach with stapled blebectomy and pleural procedure should be considered. There is no evidence to support prophylactic management of the contralateral side. Recurrence after VATS can be treated with repeat VATS with intensification of pleural treatment.

CONCLUSIONS

The management of adolescent and young adult primary spontaneous pneumothorax is varied. Best practices exist to optimize some aspects of care. Further prospective studies are needed to better determine optimal timing of operative intervention, the most effective operation, and management of recurrence after observation, tube thoracostomy, or operative intervention.

LEVEL OF EVIDENCE

Level 4.

TYPE OF STUDY

Systematic Review of Level 1-4 studies.

Predictors of initial management failure in traumatic hemothorax: A prospective multicenter cohort analysis

BACKGROUND

Traumatic hemothorax is common, and management failure leads to worse outcomes. We sought to determine predictive factors and understand the role of trauma center performance in hemothorax management failure.

METHODS

We prospectively examined initial hemothorax management (observation, pleural drainage, surgery) and failure requiring secondary intervention in 17 trauma centers. We defined hemothorax management failure requiring secondary intervention as thrombolytic administration, tube thoracostomy, image-guided drainage, or surgery after failure of the initial management strategy at the discretion of the treating trauma surgeon. Patient-level predictors of hemothorax management failure requiring secondary intervention were identified for 2 subgroups: initial observation and immediate pleural drainage. Trauma centers were divided into quartiles by hemothorax management failure requiring secondary intervention rate and hierarchical logistic regression quantified variation.

RESULTS

Of 995 hemothoraces in 967 patients, 186 (19%) developed hemothorax management failure requiring secondary intervention. The frequency of hemothorax management failure requiring secondary intervention increased from observation to pleural drainage to surgical intervention (12%, 22%, and 35%, respectively). The number of ribs fractured (odds ratio 1.12 per fracture; 95% confidence interval 1.00-1.26) and pulmonary contusion (odds ratio 2.25, 95% confidence interval 1.03-4.91) predicted hemothorax management failure requiring secondary intervention in the observation subgroup, whereas chest injury severity (odds ratio 1.58; 95% confidence interval 1.17-2.12) and initial hemothorax volume evacuated (odds ratio 1.10 per 100 mL; 95% confidence interval 1.05-1.16) predicted hemothorax management failure requiring secondary intervention after pleural drainage. After adjusting for patient characteristics in the logistic regression model for hemothorax management failure requiring secondary intervention, patients treated at high hemothorax management failure requiring secondary intervention trauma centers were 6 times more likely to undergo an intervention after initial hemothorax management failure than patients treated in low hemothorax management failure requiring secondary intervention trauma centers (odds ratio 6.18, 95% confidence interval 3.41-11.21).

CONCLUSION

Failure of initial management of traumatic hemothorax is common and highly variable across trauma centers. Assessing patient selection for a given management strategy and center-level practices represent opportunities to improve outcomes from traumatic hemothorax.

Actinomycosis with Fusobacterium empyema

Actinomyces, are gram-positive, non-spore forming anaerobic or microaerophilic species. Empyema due to actinomycosis is relatively rare and can be difficult to diagnose as the presenting symptoms may be indolent and the micro-organism may be difficult to culture. This case report describes a patient presenting with dyspnoea, weight loss and lethargy. The chest radiograph, CT and thoracic ultrasound revealed a left-sided pleural effusion. A chest drain was inserted under ultrasound guidance. The pleural fluid was macroscopically consistent with pus and microbiology showed growth of gram-positive bacilli, Actinomyces meyeri as well as the Fusobacterium species. The patient was treated with a drainage of the pleural fluid, a prolonged course of antibiotics and made a good recovery. The awareness that the Actinomyces species and the Fusobacterium species through their synergistic interaction may cause empyema, may lead to a timely diagnosis and treatment.

Safety and feasibility of a novel chest tube placement in uniportal video-assisted thoracoscopic surgery for non-small cell lung cancer

BACKGROUND

The type and placement of chest tube for patients undergoing uniportal video-assisted thoracoscopic lobectomy remains controversial. The aim of this study was to assess the efficacy and safety of a novel technique in which a pigtail catheter was used alone as the chest tube and placed near the incision for chest drainage after uniportal video-assisted thoracoscopic lobectomy and extended lymphadenectomy.

METHODS

A total of 217 patients undergoing uniportal video-assisted thoracoscopic lobectomy were retrospectively reviewed and divided into two groups. In group A, a 12-Fr pigtail catheter with several side ports was placed next to the uniportal wound. In group B, a conventional 20-Fr chest tube was placed through the uniportal wound itself. Postoperative complications related to chest tube placement and patients' subjective satisfaction were compared between the two groups. Postoperative pain management effect and other clinical outcomes such as duration of chest drainage and postoperative stay were also compared.

RESULTS

There were 112 patients in group A and 105 patients in group B. A significantly lower incidence of wound complications was found in group A postoperatively (p = 0.034). The pain score on coughing in group A was significantly lower than that in group B on postoperative day two (POD2) (p = 0.021). There was no significant difference of other clinical outcomes such as duration of chest drainage and postoperative stay as well as major complications between the two groups.

CONCLUSION

Placing a 12-Fr pigtail catheter alone next to the uniportal wound for chest drainage might be effective and safe after uniportal video-assisted thoracoscopic lobectomy and extended lymphadenectomy.

Are Chest Radiographs or Ultrasound More Accurate in Predicting a Pneumothorax or Need for a Thoracostomy Tube in Trauma Patients?

BACKGROUND

Historically, chest radiographs (CXR) have been used to quickly diagnose pneumothorax (PTX) and hemothorax in trauma patients. Over the last 2 decades, chest ultrasound (CUS) as part of Extended Focused Assessment with Sonography in Trauma (eFAST) has also become accepted as a modality for the early diagnosis of PTX in trauma patients.

METHODS

We queried our institution's trauma databases for all trauma team activations from 2021 for patients with eFAST results. Demographics, injury variables, and the following were collected: initial eFAST CUS, CXR, computed tomography (CT) scan, and thoracostomy tube procedure notes. We then compared PTX detection rates on initial CXR and CUS to those on thoracic CT scans.

RESULTS

580 patients were included in the analysis after excluding patients without a chest CT scan within 2 hours of arrival. Extended Focused Assessment with Sonography in Trauma was 68.4% sensitive and 87.5% specific for detecting a moderate-to-large PTX on chest CT, while CXR was 23.5% sensitive and 86.3% specific. Extended Focused Assessment with Sonography in Trauma was 69.8% sensitive for predicting the need for tube thoracostomy, while CXR was 40.0% sensitive.

DISCUSSION

At our institution, eFAST CUS was superior to CXR for diagnosing the presence of a PTX and predicting the need for a thoracostomy tube. However, neither test is accurate enough to diagnose a PTX nor predict if the patient will require a thoracostomy tube. Based on the specificity of both tests, a negative CXR or eFAST means there is a high probability that the patient does not have a PTX and will not need a chest tube.

Debate 1: Is the Management of Childhood Empyema Primarily Medical, or Surgical?

This review aims to discuss the role of medical and surgical therapy in the management of pediatric empyema. There is considerable debate on the optimal treatment for the same. Early intervention is crucial as it allows rapid recovery of these patients. Antibiotics and adequate pleural drainage form the two pillars in the management of empyema. Chest tube drainage alone has significant failure rates due to its inability to clear loculated effusion. The two main modalities which target these loculations to augment drainage are video-assisted thoracoscopic surgery (VATS) and intrapleural fibrinolytic therapy. The latest evidence shows that both these interventions are equally effective. Children who present late are usually not candidates for intrapleural fibrinolytic therapy or VATS; for them, decortication remains the only option.

Clinical outcomes of traumatic pneumothoraces undergoing conservative management following detection by prehospital physicians

OBJECTIVE

To describe the clinical and transport characteristics of patients diagnosed with a suspected traumatic pneumothorax and managed conservatively by prehospital medical teams including secondary deterioration during transfer and the subsequent rate of in-hospital tube thoracostomy.

METHODS

Retrospective observational study of all adult trauma patients diagnosed with a suspected pneumothorax on ultrasound and managed conservatively by their treating prehospital medical team between 2018 and 2020. Descriptive analysis was performed comparing patients who did and did not receive in-hospital tube thoracostomy.

RESULTS

In total, 181 patients were diagnosed with suspected traumatic pneumothoraces on prehospital ultrasound of which 75 (41.4%) were managed conservatively by their treating medical team whilst 106 (58.6%) underwent pleural decompression. There were no recorded cases of emergent pleural decompression required in transit. Of the 75 conservatively managed patients, 42 (56%) had an intercostal catheter (ICC) placed within four hours of hospital arrival and another nine (17.6%) had an ICC placed between four- and 24-hours post-hospital arrival. There was no significant difference in prehospital clinical characteristics between patients who did and did not receive an in-hospital ICC. The detection of a pneumothorax on the initial chest x-ray and larger pneumothorax volume visualised on computed tomography imaging were significantly more common in patients receiving in-hospital ICCs. Aviation factors including flight altitude and duration of flight were not associated with subsequent in-hospital tube thoracostomy.

CONCLUSION

Prehospital medical teams can safely identify patients who have a traumatic pneumothorax and can be transported to hospital without pleural decompression. Patient characteristics at the time of hospital arrival combined with the size of pneumothorax identified on imaging appear most likely to influence subsequent urgent in-hospital tube thoracostomy placement.

Utility of the endobronchial Watanabe spigot for intractable cancer-related pneumothorax: a retrospective observational study

BACKGROUND

The use of endobronchial Watanabe spigots for intractable secondary pneumothorax in patients with cancer has not been adequate. This study aimed to investigate the use of endobronchial Watanabe spigots for intractable pneumothorax in patients with malignant tumors.

METHODS

Consecutive patients with malignant tumors who underwent occlusion with an endobronchial Watanabe spigot for intractable pneumothorax associated with perioperative treatment or drug therapy at our institution between January 2014 and February 2022 were reviewed.

RESULTS

Of the 32 cases in which an endobronchial Watanabe spigot was used, six were excluded; we thus evaluated 26 cases in which the chest tube was removed. Chest tubes were removed in 19 cases (73.1%) and could not be removed and required surgical treatment under general anesthesia in seven patients (26.9%), of which four (14.8%) underwent open-window thoracostomy. Half of the patients were treated with both an endobronchial Watanabe spigot and pleurodesis. Although thin-slice chest computed tomography revealed a fistula in 15 patients, the chest tube was removed in 11 (57.9%) patients. A significant difference was only observed in patients with a history of heavy smoking.

CONCLUSIONS

The chest tube removal rate was comparable to those reported in previous studies. An endobronchial Watanabe spigot may be a useful treatment option for intractable cancer-related pneumothorax.

Feasibility of an improved knotless method of chest drain wound closure:a prospective cohort clinical trial

OBJECTIVE

Chest tube management plays a key role in minimising erioperative period. We have improved the knotless method to chest tube wounds. In this article, we demonstrate the clinical bility and safety of this method.

METHOD

From 13 October 2018-3 January 2019, patients were ecutively included in our study at the First Affiliated Hospital of n Medical University, Dalian, China. They were separated into approximately equally sized groups-the knotless group and the entional group. Our improved knotless method was performed ose the chest tube wounds of patients in the knotless group, and onventional method using the pre-existing U-shaped string to the chest tube wounds of patients in the conventional group. Patient clinical information, tube-related complications, retreatment s and cosmetic scores were compared between the groups.

RESULTS

The cohort comprised 102 patients; 47 in the knotless group and 55 in the conventional group. There were no statistically significant differences in patient clinical information or tube-related complications between the two groups (p>0.05; both comparisons). In the knotless group, retreatment times were shorter (p<0.001) and cosmetic scores were higher (p<0.001).

CONCLUSION

This study showed that our new knotless method is safe and has wide clinical feasibility. The new method also improved patient cosmetic scores. Furthermore, it decreased the patients' economic burdens.

A retrospective comparison between digital to conventional drainage systems for secondary spontaneous pneumothorax related to diffuse interstitial lung disease

INTRODUCTION

Secondary spontaneous pneumothorax (SSP) occurs as one of the complications associated with interstitial pneumonia (IP). Chest drainage is performed when there is a large volume of air in the pleural space. Notably, SSP with IP (SSP-IP) is frequently not curable by chest drainage only. A digital drainage system (DDS) provides an objective evaluation of air leakage and maintains a pre-determined negative pressure, compared to an analog drainage system (ADS). Few studies have reported the effectiveness of DDS in the treatment of SSP-IP. This study aimed to assess the usefulness of DDS for SSP-IP.

METHODS

This retrospective study included patients with SSP-IP who had undergone chest drainage. We reviewed the included patients' medical records, laboratory data, computed tomography findings, and pulmonary function data.

RESULTS

DDS was used in 24 patients and ADS in 49 patients. The mean duration of chest drainage was 11.4 ± 1.9 days in the DDS group and 14.2 ± 1.3 days in the ADS group, which was not significantly different (p = 0.218). Surgery, pleurodesis, and/or factor XIII administration were performed in 40 patients. Additionally, five (20.8%) patients in the DDS group and nine (18.4%) in the ADS group had a recurrence of pneumothorax within 4 weeks (p = 1.000). One patient (14%) in the DDS group and six (12.2%) in the ADS group (p = 0.414) were cured of pneumothorax but later died.

CONCLUSION

DDS did not demonstrate a significant difference in the shortening of chest drainage duration. Further study is needed to validate the results of this study.

Comparison Between Electronic and Traditional Chest Drainage Systems: A Multicenter Randomized Study

BACKGROUND

Air leak is the major factor that influences the permanence of the chest tube and the in-hospital length of stay (LOS) among patients undergoing lung resections. The aim of this study was to determine whether the use of digital chest drain systems, compared with traditional ones, reduced the duration of chest drainage and postoperative in-hospital LOS in patients undergoing video-assisted thoracoscopic (VATS) lobectomy.

METHODS

The study was a prospective, randomized, multicenter trial. Patients undergoing VATS lobectomy were randomized in 2 groups, receiving a digital drain system or a traditional one and managed accordingly to the protocol.

RESULTS

Among 503 patients who fulfilled inclusion criteria and were randomized, 38 dropped out after randomization. Finally, 465 patients were analyzed, of whom 204 used the digital device and 261 the traditional one. In the digital group, there was a significantly shorter median chest tube duration of 3 postoperative days (interquartile range [IQR], 2-4 days) vs 4 postoperative days (IQR, 3-4 days; P = .001) and postoperative in-hospital LOS of 4 days (IQR, 3-6 days) vs 5 days (IQR, 4-6 days; P = .035). Analysis of predictors for increased duration of air leaks showed a relationship with male sex (P = .039), forced expiratory volume in 1 second percentage (P = .004), forced vital capacity percentage (P = .03), and presence of air leaks at the end of surgery (P = .001).

CONCLUSIONS

In patients undergoing VATS lobectomy, the use of a digital drainage system allows an earlier removal of the chest drain compared with the traditional system, leading to a shorter in-hospital LOS.

Spontaneous Pneumothorax: Controversies in Treatment

The Research to Practice column critiques a current research article and translates the findings, in the context of a case, to a practice change within emergency settings. This article reviews the findings of a randomized controlled trial conducted by A. Theille et al. (2017) comparing the use of needle decompression versus chest tube insertion for management of spontaneous pneumothorax. The study found that use of needle aspiration was safe and effective and was associated with fewer procedure-related complications and significantly shorter hospital stays. The investigators concluded that needle aspiration be used as a first-line, definitive treatment in management of a spontaneous pneumothorax. As emergency providers examine improved and equally effective approaches to care that are associated with less costs and potential complications, needle aspiration offers a beneficial approach and should be shared with patients when discussing treatment options to ensure shared decision making.

Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial

Rationale: Management of first episodes of primary spontaneous pneumothorax remains the subject of debate. Objectives: To determine whether first-line simple aspiration is noninferior to first-line chest tube drainage for lung expansion in patients with complete primary spontaneous pneumothorax. Methods: We conducted a prospective, open-label, randomized noninferiority trial. Adults aged 18-50 years with complete primary spontaneous pneumothorax (total separation of the lung from the chest wall), recruited at 31 French hospitals from 2009 to 2015, received simple aspiration (n = 200) or chest tube drainage (n = 202) as first-line treatment. The primary outcome was pulmonary expansion 24 hours after the procedure. Secondary outcomes were tolerance of treatment, occurrence of adverse events, and recurrence of pneumothorax within 1 year. Substantial discordance in the numerical inputs used for trial planning and the actual trial rates of the primary outcome resulted in a reevaluation of the trial analysis plan. Measurement and Main Results: Treatment failure occurred in 29% in the aspiration group and 18% in the chest tube drainage group (difference in failure rate, 0.113; 95% confidence interval [CI], 0.026-0.200). The aspiration group experienced less pain overall (mean difference, -1.4; 95% CI, -1.89, -0.91), less pain limiting breathing (frequency difference, -0.18; 95% CI, -0.27, -0.09), and less kinking of the device (frequency difference, -0.05; 95% CI, -0.09, -0.01). Recurrence of pneumothorax was 20% in this group versus 27% in the drainage group (frequency difference, -0.07; 95% CI, -0.16, +0.02). Conclusions: First-line management of complete primary spontaneous pneumothorax with simple aspiration had a higher failure rate than chest tube drainage but was better tolerated with fewer adverse events. Clinical trial registered with www.clinicaltrials.gov (NCT01008228).

Effectiveness of Single Chest Tube vs Double Chest Tube Application Postdecortication: Prospective Randomized Controlled Study

BACKGROUND

Draining the chest cavity with 2 tubes is a common practice among thoracic surgeons. This research was conducted in Addis Ababa from March 2021 to May 2022. A total of 62 patients were included.

STUDY DESIGN

This study was conducted to investigate the superiority of either single or double tube insertion after decortication. Patients were randomized in a ratio of 1:1. In group A, 2 tubes were inserted; in group B, single 32F tubes were inserted. Statistical analyses were performed using Statistical Package for Social Sciences version 27.0, Student's t test and Pearson chi-square test.

RESULTS

The age range of patients was 18 to 70 years, with a mean of 44 ± 14.4434 years; the male to female ratio was 2.9:1. The dominant underlying pathologies were tuberculosis and trauma (45.2% vs 35.5%); the right side was more involved (62.3%). Drain output was 1,465 ± 1,887.9751 mL in group A vs 1,018 ± 802.5662 mL in group B (p value = 0.00001); the duration of drains was 7.5498 ± 11.3137 days in group A vs 3.8730 ± 1.4142 days in group B (p value = 0.000042). The degree of pain was 2.6458 ± 4.2426 vs 2.000 ± 2.1213 in group A and group B, respectively (p value = 0.326757). The length of hospital stay was 21.5818 ± 11.9791 days in group A vs 13.6091 ± 6.2048 days in group B (p value = 0.00001). Group A had air leak of 90.3% vs 74.2% in group B; subcutaneous emphysema was 9.7% in group A and 12.9% in group B. There was no fluid recollection, and no patients required tube reinsertion.

CONCLUSIONS

The placement of a single tube after decortication is effective in reducing drain output, time of drain, and hospital stay. There was no association with pain, and there was no effect on other endpoints.