Morbidity, mortality, and surgical treatment of secondary spontaneous pneumothorax

BACKGROUND

Pneumothorax in patients with underlying lung pathology is called secondary spontaneous pneumothorax (SSP). It is an important health problem worldwide, with significant morbidity, high health-care expenses, and possibility of mortality. This study aimed to evaluate the epidemiological characteristics, risk factors for mortality and morbidity, and treatment options of SSP.

METHODS

Outcomes of 133 patients with SSP were evaluated retrospectively. Patients with SP with evidence of underlying lung disease or a smoking history over 50 years of age were considered SSP. The patients were analyzed in terms of epidemiological fea-tures, underlying diseases, treatment methods, complications, and mortality. The treatment options included thoracotomy (T), video-assisted thoracoscopic surgery (VATS), tube thoracostomy, and conservative treatment.

RESULTS

The mean age was 50.50±20.374 years, and the age range was 16-95. Ninety-three (69.9%) of the patients were smokers. The most common clinical finding was dyspnea in 77 (57.9%) patients. The most common underlying disease was chronic obstructive pulmonary disease in 62 patients (46.6%). Six (4.5%) patients received conservative treatment, a chest tube was placed in 89 (66.9%) patients, and 38 (28.6%) patients were treated with surgery. As an operative procedure, lung wedge resection was performed in 24 (18.0%) patients and bulla resection was performed in 6 (4.5%) patients. Parietal pleurectomy was performed in 27 (20.3%) patients. Axillary mini-T or T was performed more frequently in large pneumothorax, smokers, and in obstructive pulmonary disease. Tube thoracostomy was used more frequently in poor physical performance, comorbidities, and infectious diseases. Complications were ob-served in 55 patients (41.4%). The most common complication was persistent air leakage in 18 (13.5%) patients. Complications were associated with large pneumothorax (P=0.003), poor physical performance (P=0.009), infectious diseases (P= 0.030), and occupational risk factors (P=0.032). Recurrence was developed in 12 (9.0%) patients. Postoperative recurrence was observed in 1 patient. Four (3%) patients died. Mortality was higher in patients with poor physical performance (P=0.027), comorbidities (P=0.008), and patients with complications (P=0.027). The length of stay in the hospital was high in mini-axillary T (AT)/T (P<0.001) and VATS (P<0.001). There was no significant relationship between the mini-AT/T and VATS in terms of length of hospital stay.

CONCLUSION

Large pneumothorax, poor physical performance, and comorbidity are associated with morbidity and mortality. Conservative treatment for small pneumothorax and chest tube for large pneumothorax is the most appropriate initial treatment. Resection of the bullous region through VATS or mini-AT/T is the most appropriate surgical technique.

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.

Role of Interventional Radiology in the Management of Non-aortic Thoracic Trauma

Trauma remains a leading cause of death for all age groups, and nearly two-thirds of these individuals suffer thoracic trauma. Due to the various types of injuries, including vascular and nonvascular, interventional radiology plays a major role in the acute and chronic management of the thoracic trauma patient. Interventional radiologists are critical members in the multidisciplinary team focusing on treatment of the patient with thoracic injury. Through case presentations, this article will review the role of interventional radiology in the management of trauma patients suffering thoracic injuries.

Safety and Efficacy of Indomethacin for Reducing Chest Tube Duration After Coronary Artery Bypass Grafting Surgery

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) contain a boxed warning for use in coronary artery bypass graft (CABG) surgery due to increased risk of thrombotic events, but recent research has challenged the assumption that these risks are a class effect. One anecdotal indication for NSAIDs in CABG is reducing chest tube output. Objective: The primary objective of this retrospective study was to determine whether indomethacin was associated with reduced duration of chest tube insertion after CABG surgery, defined as total chest tube duration in controls versus duration of chest tube insertion after the first dose of indomethacin in the treatment group. Secondary objectives were comparisons of daily reductions in chest tube output volume, length of stay, and safety between groups. Methods: In this retrospective, single-center case-control review, adult patients who received indomethacin after CABG were matched 1:1 to control patients based on age, sex, concomitant valve surgery, and, when possible, diabetes status. Results: Thirty-two patients were included. The mean age was 56 years and 75% were men. The primary outcome measure was 94 hours among control patients and 82.8 hours among indomethacin patients (P = 0.041). Insignificant mean reductions in daily chest tube output were observed prior to and after indomethacin initiation (38.7 vs 87.7 mL/day, P > 0.05). Conclusion: In this small, single-center study, indomethacin appeared safe and possibly effective for reducing chest tube duration after CABG surgery. Future large, prospective, randomized studies should be conducted to confirm the results.

Successful Reduction of Postoperative Chest Tube Duration and Length of Stay After Congenital Heart Surgery: A Multicenter Collaborative Improvement Project

Background Congenital heart disease practices and outcomes vary significantly across centers, including postoperative chest tube (CT) management, which may impact postoperative length of stay (LOS). We used collaborative learning methods to determine whether centers could adapt and safely implement best practices for CT management, resulting in reduced postoperative CT duration and LOS. Methods and Results Nine pediatric heart centers partnered together through 2 learning networks. Patients undergoing 1 of 9 benchmark congenital heart operations were included. Baseline data were collected from June 2017 to June 2018, and intervention-phase data were collected from July 2018 to December 2019. Collaborative learning methods included review of best practices from a model center, regular data feedback, and quality improvement coaching. Center teams adapted CT removal practices (eg, timing, volume criteria) from the model center to their local resources, practices, and setting. Postoperative CT duration in hours and LOS in days were analyzed using statistical process control methodology. Overall, 2309 patients were included. Patient characteristics did not differ between the study and intervention phases. Statistical process control analysis showed an aggregate 15.6% decrease in geometric mean CT duration (72.6 hours at baseline to 61.3 hours during intervention) and a 9.8% reduction in geometric mean LOS (9.2 days at baseline to 8.3 days during intervention). Adverse events did not increase when comparing the baseline and intervention phases: CT replacement (1.8% versus 2.0%, P=0.56) and readmission for pleural effusion (0.4% versus 0.5%, P=0.29). Conclusions We successfully lowered postoperative CT duration and observed an associated reduction in LOS across 9 centers using collaborative learning methodology.

Retrospective evaluation of fluid production at the time of thoracostomy tube removal following elective and emergency surgery in dogs (2010-2017): 185 cases

OBJECTIVE

To report the rate of fluid production at the time of removal of thoracostomy tubes placed intraoperatively and to determine the association of this rate with specific patient factors, surgical factors, or clinical diagnosis. The secondary objective was to determine whether identification of pleural effusion within 2 weeks of thoracostomy tube removal was associated with the same variables.

DESIGN

Retrospective study.

SETTING

University teaching hospital.

ANIMALS

One hundred eighty-five client-owned dogs with thoracostomy tubes placed intraoperatively between January 2010 and March 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Thoracostomy tubes were removed at a median fluid production of 0.09 mL/kg/h (range, 0-7.0 m L/kg/h). Median fluid production at the time of thoracostomy tube removal was significantly higher in dogs with preoperative pleural effusion compared to dogs without preoperative pleural effusion (0.21 vs 0.05 mL/kg/h; P = 0.0001) and in dogs that had a median sternotomy compared to dogs that had a lateral thoracotomy (0.14 vs 0.09 mL/kg/h; P = 0.04). Of the 169 dogs available for follow-up, 12 (7.1%) had pleural effusion within 2 weeks of removal of the thoracostomy tube. Detection of pleural effusion during the follow-up period was significantly associated with the presence of preoperative pleural effusion (P = 0.0019) and the diagnosis (P = 0.01). A greater proportion of dogs with a lung lobe torsion (4/9, 44.4%) and idiopathic chylothorax (2/7, 28.5%) had pleural effusion within 2 weeks compared to other diagnoses. Reintervention was performed in 4.7% of dogs.

CONCLUSIONS

Thoracostomy tubes were removed at pleural fluid production rates that frequently exceeded current veterinary guidelines. However, the fluid production rate at the time of thoracostomy tube removal was not associated with the detection of pleural effusion within 2 weeks of thoracostomy tube removal, and the overall need for reintervention following thoracostomy tube removal was low (4.7%).

The relationship between pain severity and sleep quality: Posttube thoracostomy

BACKGROUND

The presence of a chest tube is a factor significantly associated with pain and pain posttube thoracostomy that negatively affects sleep quality (SQ).

AIM

To determine the relationship between the pain severity and SQ of patients who underwent the tube thoracostomy (TT).

METHODS

This was a descriptive and cross-sectional survey conducted from May 1, 2018, to December 30, 2018, in the thoracic surgery department of Sivas Cumhuriyet University Hospital in Central Anatolia/Turkey. Data were collected using a questionnaire form, a Numerical Rating Scale to determine pain severity, and the Richard-Campbell Sleep Questionnaire to assess SQ.

RESULTS

The study was carried out with 102 patients who underwent the TT. The mean age of the participants were 48.94 years. The mean scores for the scale items indicated that during the procedure and on the first day of post-TT, the pain severity of the patients was very high, their SQ was low. Pain level decreased gradually in the following days, and the SQ increased. There was a positive, strong correlation between the post-TT first day pain and first night SQ (r = 0.380, p = 0.000), second day pain and second night SQ (r = -0.537, p = 0.000), and third day pain and third night SQ (r = -0.507, p = 0.000).

CONCLUSION

The results of this study highlight that the pain severity of post-TT significantly affect the quality of the patients' night sleep.

Small Drainage Volumes of Pleural Effusions Are Associated with Complications in Critically Ill Patients: A Retrospective Analysis

Pleural effusions are a common finding in critically ill patients and small bore chest drains (SBCD) are proven to be efficient for pleural drainage. The data on the potential benefits and risks of drainage remains controversial. We aimed to determine the cut-off volume for complications, to investigate the impact of pleural drainage and drained volume on clinically relevant outcomes. Medical records of all critically ill patients undergoing insertion of SBCD were retrospectively examined. We screened 13,003 chest radiographs and included 396 SBCD cases in the final analysis. SBCD drained on average 900 mL, with less amount in patients with complications (p = 0.003). A drainage volume of 975 mL in 24 h represented the optimal threshold for complications. Pneumothorax was the most frequent complication (4.5%), followed by bleeding (0.8%). Female and lighter-weighted patients experienced a higher risk for any complication. We observed an improvement in the arterial partial pressure of oxygen and respiratory quotient (p < 0.001). We conclude that the small drainage volumes are associated with complications in critically ill patients—the more you drain, the safer the procedure gets. The use of SBCD is a safe and efficient procedure, further investigations regarding the higher rate of complications in female and lighter-weighted patients are desirable.

Clinical course of asymptomatic malignant pleural effusion in non-small cell lung cancer patients: A multicenter retrospective study

The British Thoracic Society guidelines recommend observation for patients with asymptomatic malignant pleural effusion (MPE). However, asymptomatic MPE can become symptomatic. This study examined the clinical course of asymptomatic MPE in patients with non-small cell lung cancer (NSCLC), including the incidence and timing of symptom development of asymptomatic MPE and the associated factors.Retrospective data of 4822 NSCLC patients between January 2012 and December 2017 were reviewed. Symptom development of asymptomatic MPE was defined as the development of symptoms requiring additional treatment, such as insertion of a chest tube, within 1 year in patients who lacked MPE symptoms at the time of diagnosis. Clinical information, pathological parameters, and radiological characteristics were reviewed. Patient data up to 1 year from the initial diagnosis were reviewed.Of 113 patients with asymptomatic MPE, 46 (41%) became symptomatic within 1 year despite appropriate anticancer treatment. The median time to symptom development was 4 months, and 38 patients (83%) developed symptoms within 6 months. Multivariate logistic regression showed that female sex (odds ratio [OR], 0.256; 95% confidence interval [CI], 0.101-0.649; P = .004) and the depth of pleural effusion on initial computed tomography (CT) (OR, 0.957; 95% CI, 0.932-0.982; P = .001) were independently associated with symptom development of asymptomatic MPE.A fraction of 41% of patients with asymptomatic MPE became symptomatic within 1 year. Female sex and larger MPE on initial CT were independently associated with symptom development of asymptomatic MPE.

Damage control surgery in lung trauma

Damage control techniques applied to the management of thoracic injuries have evolved over the last 15 years. Despite the limited number of publications, information is sufficient to scatter some fears and establish management principles. The severity of the anatomical injury justifies the procedure of damage control in only few selected cases. In most cases, the magnitude of the physiological derangement and the presence of other sources of bleeding within the thoracic cavity or in other body compartments constitutes the indication for the abbreviated procedure. The classification of lung injuries as peripheral, transfixing, and central or multiple, provides a guideline for the transient bleeding control and for the definitive management of the injury: pneumorraphy, wedge resection, tractotomy or anatomical resection, respectively.

Identification of specific patterns such as the need for resuscitative thoracotomy, or aortic occlusion, the existence of massive hemothorax, a central lung injury, a tracheobronchial injury, a major vascular injury, multiple bleeding sites as well as the recognition of hypothermia, acidosis or coagulopathy, constitute the indication for a damage control thoracotomy. In these cases, the surgeon executes an abbreviated procedure with packing of the bleeding surfaces, primary management with packing of some selected peripheral or transfixing lung injuries, and the postponement of lung resection, clamping of the pulmonary hilum in the most selective way possible. The abbreviation of the thoracotomy closure is achieved by suturing the skin over the wound packed, or by installing a vacuum system. The management of the patient in the intensive care unit will allow identification of those who require urgent reintervention and the correction of the physiological derangement in the remaining patients for their scheduled reintervention and definitive management.

Damage control in penetrating cardiac trauma

Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients.

Clinical application of a digital thoracic drainage system for objectifying and quantifying air leak versus the traditional vacuum system: a retrospective observational study

Background

Digital thoracic drainage systems have recently been introduced and widely used in clinical practices in developed countries. These systems can monitor intrathoracic pressure changes and air leaks in real time, and also allow for objective and quantitative analyses, which aid in managing patients with a prolonged persistent air leak into the pleural space. We investigated the feasibility and effectiveness of such a new device versus the traditional vacuum system for treating patients with pneumothorax.

Methods

Closed thoracostomy drainage was carried out on 100 adult patients with primary or secondary pneumothorax between January 2017 and December 2018. All the patients were aged ≥18 years and treated with a chest tube at a single medical center by the same cardiothoracic surgeons and intensivists. Patients who underwent closed thoracostomy drainage using an indwelling 24-French chest tube were divided into 2 groups immediately before closed thoracostomy: the digital thoracic drainage group (digital group, n=50) and the traditional analogue thoracic drainage group (analogue group, n=50). The detailed information about demographic data, treatment outcome, duration of indwelling catheterization., hospital days, cost-effectiveness and patient satisfaction was evaluated. We also evaluated whether digitally recorded intrapleural pressure changes and air leaks would predict chest tube removal timing and outcome.

Results

The baseline parameters of the 2 groups were comparable with no significant differences in sex, age, weight or body mass index. The mean hospital day was shorter in the digital group than in the analogue group (17.96±12.23 vs. 18.32±16.64, P=0.902), and there was no statistically significant difference in the hospital length of stay between the 2 groups. Air leaks through the chest tube and duration of chest tube indwelling hours showed no significant statistical differences between the digital and analogue groups (213.47±219.80 vs. 261.94±184.47, P=0.235 and 223.44±218.75 vs 275.29±186.06, P=0.205, respectively). Total drainage amount and ambulation time per day were significantly higher in the digital group than in the analogue group [209.62±139.63 vs. 162.48±80.42 (P=0.042) and 6.42±3.62 vs.3.94±1.74 (P<0.001), respectively]. Hours of full expansion were significantly shorter and sleep disturbance caused by the noise of chest tube drainage was less in the digital group than in the analogue group [25.64±14.55 vs. 46.52±25.53 (P<0.001) and 2.38±1.03 vs. 5.70±2.87 (P<0.001), respectively].

Conclusions

To date, there is no definite consensus and guidelines on the standardized digital suction system in pneumothorax. This study proposed the guidelines for the application of digital thoracic drainage systems in pneumothorax and also suggested that digital thoracic drainage systems might be a valuable tool to determine chest tube removal timing and reducing the length of hospital stay in patients with pneumothorax.

Cold Therapy and Respiratory Relaxation Exercise on Pain and Anxiety Related to Chest Tube Removal: A Clinical Trial

Background:

Current strategies to control pain and anxiety of chest tube removal are not efficacious. The aim of this study is to determine the effects of cold therapy and respiratory relaxation exercise on pain and anxiety of chest tube removal.

Materials and Methods:

A parallel single-blind clinical trial study was conducted in Imam Khomeini Hospital, Iran, on 120 patients. Participants were randomized into 4 groups of 30. Numeric Rating Scale was used to assess pain and anxiety. One-way ANOVA test and Fisher's exact test were used to analyze demographic data. The Kruskal–Wallis test was used to compare the severity of pain and anxiety between groups; the Friedman and Mann–Whitney test were used to compare the severity of pain and anxiety within groups with a significance level of 0.05.

Results:

Pain intensity was weak before chest tube removal and there was no significant difference in basal pain. Pain immediately after chest tube removal was significantly higher than other times in each group (χ² = 57.16, χ² = 63.70, χ² = 46.49, χ² = 59.04, df = 3, p < 0.001). There was no significant difference in pain score immediately (p = 0.052) and 15 min (p = 0.329) after Echest tube removal in experimental groups compared to the control group. No significant difference was found between control and experimental groups in anxiety score immediately (p = 0.995) and 15 min (p = 0.976) before chest tube removal.

Conclusions:

Mentioned methods were not effective in reducing pain and anxiety. It is suggested to investigate effects of different methods of removing chest tubes and applying cold with a larger sample size.

Management of Pleural Effusions in the Emergency Department

BACKGROUND

In symptomatic patients, admitted in emergency department for acute chest pain and dyspnea, who require an urgent treatment, a rapid diagnosis and prompt management of massive pleural effusion or hemothorax can be lifesaving.

AIM

The aim of this review was to summarize the current diagnostic and therapeutic approaches for the management of the main types of pleural effusions that physicians can have in an emergency department setting.

METHODS

Current literature about the topic was reviewed and critically reported, adding the experience of the authors in the management of pleural effusions in emergency settings.

RESULTS

The paper analyzed the main types of pleural effusions that physicians can have to treat. It illustrated the diagnostic steps by the principal radiological instruments, with a particular emphasis to the role of ultrasonography, in facilitating diagnosis and guiding invasive procedures. Then, the principal procedures, like thoracentesis and insertion of small and large bore chest drains, are indicated and illustrated according to the characteristics and the amount of the effusion and patient clinical conditions.

CONCLUSION

The emergency physician must have a systematic approach that allows rapid recognition, clinical cause identification and definitive management of potential urgent pleural effusions.

Development and Evaluation of Motion-activated System for Improved Chest Drainage: Bench, In Vivo Results, and Pilot Clinical Use of Technology

Objective. The aim of this study was to evaluate a motion-activated system (MAS) that applies motion-activated energy (vibration) to prevent chest tube clogging and maintain tube patency. We performed chest tube blood flow analysis in vitro, studied MAS effects on intraluminal clot deposition in vivo, and conducted a pilot clinical test. Background. Chest tube clogging is known to adversely contribute to postoperative cardiac surgery outcomes. Methods. The MAS was tested in vitro with a blood-filled chest tube model for device acceleration and performance. In vivo acute hemothorax studies (n = 5) were performed in healthy pigs (48.0 ± 2 kg) to evaluate the drainage in MAS versus control (no device) groups. Using a high-speed camera (FASTCAM Mini AX200, 100 mm Zeiss lens) in an additional animal study (n = 1), intraluminal whole-blood activation imaging of the chest tube (32 Fr) was made. The pilot clinical study (n = 12) consisted of up to a 30 minutes device tolerance test. Results. In vitro MAS testing suggested optimal device performance. The 2-hour in vivo evaluation showed a longer incremental drainage in the MAS group versus control. The total drainage in the MAS group was significantly higher than that in the control group (379 ± 144 mL vs 143 ± 40 mL; P = .0097), indicating tube patency. The high-speed camera images showed a characteristic intraluminal blood "swirling" pattern. Clinical data showed no discomfort with the MAS use (pleural = 4; mediastinal = 8). Conclusions. The MAS showed optimal performance at bench and better drainage profile in vivo. The clinical trial showed patients' tolerance to the MAS and device safety.

Effect of overhang and stiffness on accessibility of catheter tip to lung defects under surgical constraints

Background

Steering a catheter tip to a defective spot on a lung during fibrin glue application under pleurography (FGAP) constitutes a very challenging task. Accurate control of tip position/slope of steerable catheters is critical for providing glue to air-leaking defects on lung during FGAP. Steerable catheters are composed of multiple segments with different flexural rigidities and experience nonlinear deformation. Therefore, predicting tip position with accuracy is difficult. The purpose of this paper is to present a novel method that can accurately control the tip of the catheter, and thus enhance its target accessibility.

Methods

The tip position of a deflected steerable catheter can be accurately predicted using a simulation tool depicting the curvature of a bent catheter based on a mechanics of materials analysis. The proposed method utilizes the simulation tool to enhance the target accessibility of the catheter’s tip. This assists medical doctors to not only select the optimal catheter prior to operation, but also to steer the catheter to the defects effectively. Simulation reliability is tested by performing a catheter deflection experiment and measuring the tip position.

Results

The simulation result accurately predicts the location of the catheter tip with an error of less than 5 mm to the experimental results.

Conclusions

Controlling pull-wire tensions and overhang lengths based on simulation results substantially improves the target accessibility of the catheter tip.

Effect of puncture sites on pneumothorax after lung CT-guided biopsy

To determine the influence of puncture site on aspiration in dealing with pneumothorax following CT-guided lung biopsy.Two hundred thirty-six pneumothorax patients after CT guided lung biopsies were retrospective analyzed from January 2013 to December 2018. Patients with minor asymptomatic pneumothorax were treated conservatively with monitoring of vital signs and follow-up CT to confirm stability. Ninety of the 236 pneumothorax patients, who underwent manual aspiration, were included in this analysis. In first manual aspiration, the needle from the lesion was retracted back into the pleural space after biopsy, and then aspiration treatment was performed. If the treatment is of unsatisfied result, a second attempt aspiration treatment, which puncture site away from initial biopsy one, was conducted. The efficacy of simple manual aspiration and the new method, changing puncture site for re-aspiration was observed.Immediate success was obtained in 62 out of the 90 patients in the first attempt. The effective rate and failure rate were 68.9% (62/90) and 31.1% (28/90), respectively. Twenty-eight patients in whom first attempt simple aspiration were unsuccessful underwent a second attempt aspiration, which puncture site away from initial biopsy one, was successful in 13 patients with 15 patients undergoing chest tube placement. The effective rate and failure rate were 46.4% (13/28) and 53.6% (15/28), respectively. Applying the modified procedure, total effective rate of aspiration elevated significantly from 68.9% (62/90) to 83.3% (75/90) (P < .05). No serious side effects were detected in the period of aspiration procedure.Manual aspiration with puncture site away from initial biopsy one is worth trying to deal with post-biopsy pneumothorax. This modified procedure improved the efficiency of treatment significantly, and reduced the rate of pneumothorax requiring chest tube placement.

Pediatric empyema thoracis: roles and outcomes of surgery in advanced disease

Aim

Empyema thoracis has become increasingly common in the pediatric population. Antibiotics and thoracostomy have been the cornerstones of management of stage 1 empyema, whereas management of stage 2 and 3 empyema remains controversial. Surgical intervention is perceived to be associated with high morbidity and protracted recovery. We aimed to review the role and outcome of surgical decortication, and provide data for comparison with other treatment modalities.

Methods

The medical records and clinical outcomes of 30 children (median age 5.2 years) with stage 2 or 3 empyema, who underwent surgical decortication from September 2017 to September 2019, were reviewed.

Results

Most children were referred for decortication by day 8.8 ± 4 of admission, and the median time from referral to surgery was 2.2 ± 2 days. All patients had tube thoracostomy, and 5 (17%) underwent fibrinolysis prior to surgery. Twenty-one (70%) patients required pediatric intensive care unit admission preoperatively. Postoperatively, most patients were extubated on day 2.5 (range 1–4 days), with chest tubes removed on day 3.8 (range 1–7 days). Most were discharge by day 6.2 (range 4–10 days). Postoperative air leak occurred in one (3%) patient. There was no mortality or reoperation.

Conclusion

Surgical decortication remains an excellent modality for managing stage 2 and 3 pediatric empyema. The procedure has a low morbidity and provides rapid resolution of symptoms with good clinical outcomes if performed promptly. Delayed referral may result in a more protracted clinical course.

Active chest tube clearance after aortic valve surgery did not influence amount residual pericardial fluid after aortic valve replacement in a randomised trial

Objective. Evaluate if the use of active clearance of chest tubes after aortic valve surgery influenced bleeding and reduced postoperative residual pericardial effusion. Design. Prospective randomised trial comparing PleuraFlow^® 32 F chest tube with FlowGlide™ active clearance to a standard Argyle^® 32 F chest tube in 100 patients undergoing aortic valve surgery. Chest tube outputs and pericardial effusion measurements assessed by two-dimensional transthoracic echocardiography were recorded before hospital discharge. Results. Postoperative chest tube outputs per hour did not differ between the two groups. The median chest tube output was 400 mL for patients who had a PleuraFlow^® chest tube vs. 490 mL for patients with an Argyle^® chest tube (p = .08). Pericardial effusions ≥ 2 mm were detected in 76% vs. 68% of the patients (p = .50) and postoperative atrial fibrillation occurred in 42% vs. 34% (p = .54), respectively. Conclusions. Use of active clearance chest tubes, compared to standard chest tubes after aortic valve surgery did not differ significantly regarding postoperative bleeding or degree of pericardial effusion as measured by echocardiography prior to hospital discharge.

Evaluation of a Mobile Telesimulation Unit to Train Rural and Remote Practitioners on High-Acuity Low-Occurrence Procedures: Pilot Randomized Controlled Trial

Background

The provision of acute medical care in rural and remote areas presents unique challenges for practitioners. Therefore, a tailored approach to training providers would prove beneficial. Although simulation-based medical education (SBME) has been shown to be effective, access to such training can be difficult and costly in rural and remote areas.

Objective

The aim of this study was to evaluate the educational efficacy of simulation-based training of an acute care procedure delivered remotely, using a portable, self-contained unit outfitted with off-the-shelf and low-cost telecommunications equipment (mobile telesimulation unit, MTU), versus the traditional face-to-face approach. A conceptual framework based on a combination of Kirkpatrick’s Learning Evaluation Model and Miller’s Clinical Assessment Framework was used.

Methods

A written procedural skills test was used to assess Miller’s learning level— knows —at 3 points in time: preinstruction, immediately postinstruction, and 1 week later. To assess procedural performance (shows how), participants were video recorded performing chest tube insertion before and after hands-on supervised training. A modified Objective Structured Assessment of Technical Skills (OSATS) checklist and a Global Rating Scale (GRS) of operative performance were used by a blinded rater to assess participants’ performance. Kirkpatrick’s reaction was measured through subject completion of a survey on satisfaction with the learning experiences and an evaluation of training.

Results

A total of 69 medical students participated in the study. Students were randomly assigned to 1 of the following 3 groups: comparison (25/69, 36%), intervention (23/69, 33%), or control (21/69, 31%). For knows, as expected, no significant differences were found between the groups on written knowledge (posttest, P=.13). For shows how, no significant differences were found between the comparison and intervention groups on the procedural skills learning outcomes immediately after the training (OSATS checklist and GRS, P=1.00). However, significant differences were found for the control versus comparison groups (OSATS checklist, P<.001; GRS, P=.02) and the control versus intervention groups (OSATS checklist, P<.001; GRS, P=.01) on the pre- and postprocedural performance. For reaction, there were no statistically significant differences between the intervention and comparison groups on the satisfaction with learning items (P=.65 and P=.79) or the evaluation of the training (P=.79, P=.45, and P=.31).

Conclusions

Our results demonstrate that simulation-based training delivered remotely, applying our MTU concept, can be an effective way to teach procedural skills. Participants trained remotely in the MTU had comparable learning outcomes (shows how) to those trained face-to-face. Both groups received statistically significant higher procedural performance scores than those in the control group. Participants in both instruction groups were equally satisfied with their learning and training (reaction). We believe that mobile telesimulation could be an effective way of providing expert mentorship and overcoming a number of barriers to delivering SBME in rural and remote locations.

Spontaneous Hemothorax in a Patient with von Recklinghausen's Disease: A Case Report and Review of the Literature

BACKGROUND Von Recklinghausen's disease, also known as Type 1 neurofibromatosis (NF1), is a genetic disorder characterized by skin tumors, neurofibromas of multiple organs and vascular abnormalities. Spontaneous thoracic hemorrhage is a rare but potentially fatal consequence of this disorder. After a review of the literature over the last 10 years and on the basis of a case study, the aim of this study was to report the challenges of management of this pathology. CASE REPORT We report a rare case of a 45-years-old male with a medical history of neurofibromatosis who complained of a 3-day history of progressive dyspnea. At his admission to the Emergency Department, the patient was hemodynamically stable. A chest computed tomography (CT) scan showed a large left hemothorax with mediastinal shift to the right without active bleeding. A chest tube was introduced, and conservative treatment was followed. Another CT scan performed 2 days later revealed a middle lobar pulmonary embolism on the opposite side. A full treatment of anticoagulation was administered, and the patient was released after 8 days of hospitalization. Three weeks later, a new chest CT scan indicated the absence of vascular aneurysm or source for hemothorax. CONCLUSIONS Our systematic literature review found 15 articles which were described as early as 2005. To our knowledge, endovascular treatment produces the best immediate successful result (100%) and may be used in adjunction with video-assisted thorax surgery (VATS) or thoracic drainage to optimize outcomes. In the present case, conservative treatment showed a good result despite anticoagulation for pulmonary embolism. The endovascular approach seems to be the most promising, but treatment needs to be tailored to each individual patient.

Fish Oil and Perioperative Bleeding

Background Fish oil is among the most common natural supplements for treatment of hypertriglyceridemia or prevention of cardiovascular disease. However, concerns about theoretical bleeding risk have led to recommendations that patients should stop taking fish oil before surgery or delay in elective procedures for patients taking fish oil by some health care professionals. Methods and Results We tested the effect of fish oil supplementation on perioperative bleeding in a multinational, placebo-controlled trial involving 1516 patients who were randomized to perioperative fish oil (eicosapentaenoic acid+docosahexaenoic acid; 8-10 g for 2-5 days preoperatively, and then 2 g/d postoperatively) or placebo. Primary outcome was major perioperative bleeding as defined by the Bleeding Academic Research Consortium. Secondary outcomes include perioperative bleeding per thrombolysis in myocardial infarction and International Society on Thrombosis and Hemostasis definitions, chest tube output, and total units of blood transfused. Participants' mean (SD) age was 63 (13) years, and planned surgery included coronary artery bypass graft (52%) and valve surgery (50%). The primary outcome occurred in 92 patients (6.1%). Compared with placebo, risk of Bleeding Academic Research Consortium bleeding was not higher in the fish oil group: odds ratio, 0.81; 95% CI, 0.53-1.24; absolute risk difference, 1.1% lower (95% CI, -3.0% to 1.8%). Similar findings were seen for secondary bleeding definitions. The total units of blood transfused were significantly lower in the fish oil group compared with placebo (mean, 1.61 versus 1.92; P<0.001). Evaluating achieved plasma phospholipid omega-3 polyunsaturated fatty acids levels with supplementation (on the morning of surgery), higher levels were associated with lower risk of Bleeding Academic Research Consortium bleeding, with substantially lower risk in the third (odds ratio, 0.30 [95% CI, 0.11-0.78]) and fourth (0.36 [95% CI, 0.15-0.87]) quartiles, compared with the lowest quartile. Conclusions Fish oil supplementation did not increase perioperative bleeding and reduced the number of blood transfusions. Higher achieved n-3-PUFA levels were associated with lower risk of bleeding. These novel findings support the need for reconsideration of current recommendations to stop fish oil or delay procedures before cardiac surgery. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT00970489.

Recurrent spontaneous pneumothorax in pregnancy - a case report and review of literature

Spontaneous pneumothorax in pregnancy is a rare and life-threatening condition. In this report, a case of spontaneous pneumothorax occurring at 34 weeks’ gestation in a healthy 34-year-old primigravida is described. She had typical complaints of chest pain and dyspnoea and diagnosis was made by chest X-ray which showed an extensive pneumothorax in the right side. Pneumothorax recurred twice over approximately three weeks. A caesarean section secondary to small pelvic parameters was scheduled with the chest tube in situ and a healthy 2.5 kg female infant was delivered. We discuss spontaneous pneumothorax during pregnancy and review the literature.

Evaluation of App-Based Serious Gaming as a Training Method in Teaching Chest Tube Insertion to Medical Students: Randomized Controlled Trial

BACKGROUND

The insertion of a chest tube should be as quick and accurate as possible to maximize the benefit and minimize possible complications for the patient. Therefore, comprehensive training and assessment before an emergency situation are essential for proficiency in chest tube insertion. Serious games have become more prevalent in surgical training because they enable students to study and train a procedure independently, and errors made have no effect on patients. However, up-to-date evidence regarding the effect of serious games on performance in procedures in emergency medicine remains scarce.

OBJECTIVE

The aim of this study was to investigate the serious gaming approach in teaching medical students an emergency procedure (chest tube insertion) using the app Touch Surgery and a modified objective structural assessment of technical skills (OSATS).

METHODS

In a prospective, rater-blinded, randomized controlled trial, medical students were randomized into two groups: intervention group or control group. Touch Surgery has been established as an innovative and cost-free app for mobile devices. The fully automatic software enables users to train medical procedures and afterwards self-assess their training effort. The module chest tube insertion teaches each key step in the insertion of a chest tube and enables users the meticulous application of a chest tube. In contrast, the module "Thoracocentesis" discusses a basic thoracocentesis. All students attended a lecture regarding chest tube insertion (regular curriculum) and afterwards received a Touch Surgery training lesson: intervention group used the module chest tube insertion and the control group used Thoracocentesis as control training. Participants' performance in chest tube insertion on a porcine model was rated on-site via blinded face-to-face rating and via video recordings using a modified OSATS tool. Afterwards, every participant received an individual questionnaire for self-evaluation. Here, trainees gave information about their individual training level, as well as previous experiences, gender, and hobbies. Primary end point was operative performance during chest tube insertion by direct observance.

RESULTS

A total of 183 students enrolled, 116 students participated (63.4%), and 21 were excluded because of previous experiences in chest tube insertion. Students were randomized to the intervention group (49/95, 52%) and control group (46/95, 48%). The intervention group performed significantly better than the control group (Intervention group: 38.0 [I₅₀=7.0] points; control group: 30.5 [I₅₀=8.0] points; P<.001). The intervention group showed significantly improved economy of time and motion (P=.004), needed significantly less help (P<.001), and was more confident in handling of instruments (P<.001) than the control group.

CONCLUSIONS

The results from this study show that serious games are a valid and effective tool in education of operative performance in chest tube insertion. We believe that serious games should be implemented in the surgical curriculum, as well as residency programs, in addition to traditional learning methods.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) DRKS00009994; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00009994 (Archived by Webcite at http://www.webcitation.org/6ytWF1CWg).

Variation in nurse self-reported practice of managing chest tubes: A cross-sectional study

AIMS AND OBJECTIVES

To reveal nurses' self-reported practice of managing chest tubes and to define decision-makers for these practices.

BACKGROUND

No consensus exists regarding ideal chest-tube management strategy, and there are wide variations of practice based on local policies and individual preferences, rather than standardised evidence-based protocols.

DESIGN

This article describes a cross-sectional study.

METHODS

Questionnaires were emailed to 31 hospitals in Tianjin, and the sample consisted of 296 clinical nurses whose work included nursing management of chest drains. The questionnaire, which was prepared by the authors of this research, consisted of three sections, including a total of 22 questions that asked for demographic information, answers regarding nursing management that reflected the practice they actually performed and who the decision-makers were regarding eight chest-drain management procedures. McNemar's test was used to analyse the data.

RESULTS

The results indicated that most respondents thought that it was necessary to manipulate chest tubes to remove clots impeding unobstructed drainage (91.2%). Most respondents indicated that dressings would be changed when the dressing was dysfunctional. At the same time, more than half of respondents approved of changing dressings routinely, and the frequency of changing dressings varied. When drainage was employed for pleural effusion and for a pneumothorax, 64.6% and 94.5% of respondents, respectively, considered that underwater seal-drainage bottles should be changed routinely, and the frequency of changing bottles both varied. The results indicated that nurses were the primary decision-makers in the replacement of chest tubes, manipulation of chest tubes and monitoring of drainage fluid.

CONCLUSIONS

There was considerable variation in respondents' self-reported clinical nursing practice regarding management of chest drains. The rationale on which respondents' practices were based also varied greatly. This study indicated that nurses were the primary decision-makers for three of eight procedures regarding management of chest drains, which reflects that clinical nurses' decision-making power regarding management of chest drains was weak.

RELEVANCE TO CLINICAL PRACTICE

This study describes the nurse-reported practices of Chinese nurses from Tianjin, including changing and selecting dressing types, manipulating chest tubes, clamping drains and replacing drainage bottles, and the study defines who the decision-makers were for these interventions. By focusing on nurses' self-report of behaviours in managing chest drains (actual nursing practice vs. nursing knowledge), this article also relates the literature to the research findings and denotes the gaps in knowledge for future research.

Efficacy of cold application on pain during chest tube removal: a randomized controlled trial: A CONSORT-compliant article

BACKGROUND

Use of analgesics is the most common method to alleviate the pain induced by chest tube removal (CTR), but patient response to medication can vary and may not be achieved complete relaxation. This study was to determine the effectiveness of cold application in combination with standard analgesic administration before CTR on CTR-induced pain.

METHODS

A prospective, randomized, single-blind, sham-controlled study was conducted. In addition to the same routine care, subjects in the experimental group (n = 30) received cold application of 600-g ice packs 15 minutes before CTR, whereas subjects in the sham group (n = 30) received tap water packs. Numerical rating scale was used to measure pain intensity before, immediately after, and 10 minutes after CTR.

RESULTS

The generalized linear estimating equation (GEE) model, adjusted for other factors, both the groups demonstrated a trend toward decreased pain during CTR over time (P < .001), but no significant differences between the 2 groups (P = .65), even stratifying by gender. If we fixed experimental group, women significant reduced pain score of 2.7 on immediately after CTR compared with before CTR (P < .0001) and reduced pain score of 2.05 on 10 minutes after CTR compared with before CTR (P < .0001). The sham group had no similar performance as the experimental group. In the male subgroup, both experimental and sham groups, men significantly reduced pain score on immediately after CTR and 10 minutes after CTR compared with before CTR (P < .0001).

CONCLUSION

The results indicate that cold application is not more effective than sham treatment in decreasing pain during CTR, even among gender. Although statistically non-significant, clinically important differences of decreased pain score were observed with cold application among women (Clinical Trial Registration: clinicaltrials.gov identifier NCT03307239).

The usefulness of Wi-Fi based digital chest drainage system in the post-operative care of pneumothorax

BACKGROUND

Chest drainage systems are usually composed of chest tube and underwater-seal bottle. But this conventional system may restrict patients doing exercise and give clinicians obscure data about when to remove tubes because there is no objective indicator. Recently developed digital chest drainage systems may facilitate interpretation of the grade of air leak and make it easy for clinicians to decide when to remove chest tubes. In addition, with combination of wireless internet devices, monitoring and managing of drainage system distant from the patient is possible.

METHODS

Sixty patients of primary pneumothorax were included in a prospective randomized study and divided into two groups. Group I (study) consisted of digital chest drainage system while in group II (control), conventional underwater-seal chest bottle system was used. Data was collected from January, 2012 to September, 2013 in Eulji University Hospital, Daejeon, Korea.

RESULTS

There was no difference in age, sex, smoking history and postoperative pain between two groups. But the average length of drainage was 2.2 days in group I and 3.1 days in group II (P<0.006). And more, about 90% of the patients in group I was satisfied with using new device for convenience.

CONCLUSIONS

Digital system was beneficial on reducing the length of tube drainage by real time monitoring. It also had advantage in portability, loudness and gave more satisfaction than conventional system. Moreover, internet based digital drainage system will be a good method in thoracic telemedicine area in the near future.

Air leak after lung resection: pathophysiology and patients' implications

Protocols for the management of air leaks are critical aspects in the postoperative course of patients following lung resections. Many investigations in the last decade are focusing on the chest tube modalities or preventative measures, however, little is known about the pathophysiology of air leak and the patient perception of this common complication. This review concentrates on understanding the reasons why a pulmonary parenchyma may start to leak or an air leak may be longer than others. Experimental works support the notion that lung overdistension may favor air leak. These studies may represent the basis of future investigations. Furthermore, the standardization of nomenclature in the field of pleural space management and the creation of novel air leak scoring systems have contributed to improve the knowledge among thoracic surgeons and facilitate the organization of trials on this matter. We tried to summarize available evidences about the patient perception of a prolonged air leak and about what would be useful for them in order to prevent worsening of their quality of life. Future investigations are warranted to better understand the pathophysiologic mechanisms responsible of prolonged air leak in order to define tailored treatments and protocols. Improving the care at home with web-based telemonitoring or real time connected chest drainage may in a future improve the quality of life of the patients experience this complication and also enhance hospital finances.

Procedural pain does not raise plasma levels of cortisol or catecholamines in adult intensive care patients after cardiac surgery

The gold standard for quantification of pain is a person's self-report. However, we need objective parameters for pain measurement when intensive care patients, for example, are not able to report pain themselves. An increase in pain is currently thought to coincide with an increase in stress hormones. This observational study investigated whether procedure-related pain is associated with an increase of plasma cortisol, adrenaline, and noradrenaline. In 59 patients receiving intensive care after cardiac surgery, cortisol, adrenaline, and noradrenaline plasma levels were measured immediately before and immediately after patients were turned for washing, either combined with the removal of chest tubes or not. Numeric rating scale scores were obtained before, during, and after the procedure. Unacceptably severe pain (numeric rating scale ≥ 4) was reported by seven (12%), 26 (44%), and nine (15%) patients, before, during and after the procedure, respectively. There was no statistically significant association between numeric rating scale scores and change in cortisol, adrenaline, and noradrenaline plasma levels during the procedure. Despite current convictions that pain coincides with an increase in stress hormones, procedural pain was not associated with a significant increase in plasma stress hormone levels in patients who had undergone cardiac surgery. Thus, plasma levels of cortisol, adrenaline, and noradrenaline seem unsuitable for further research on the measurement of procedural pain.

Discharge of thoracic patients on portable digital suction: Is it cost-effective?

OBJECTIVES

A portable suction drainage device for patients undergoing thoracic surgical procedures was introduced into our service in January 2010. Patients who met strict discharge criteria were allowed to continue their treatment at home with the device. They were monitored in a designated follow-up clinic. Data were collected to identify the impact of this service in relation to the duration of follow-up required, bed-days saved, and potential cost/benefits.

METHODS

All patients who underwent a thoracic procedure from March 2012 to April 2014 and required suction postoperatively for air leak were included in the study. Patients were identified as suitable according to the discharge criteria. Data regarding patient demographics were collected prospectively on the thoracic database, and data on the drainage device were logged in a specific data sheet. Visits to the follow-up clinic were also recorded.

RESULTS

During the study period, 50 patients stayed a total 1125 days on the portable suction system. Twenty were discharged home, equating to 772 bed-days saved (GBP 270,000 cost-saving). Clinic attendance totalled 162 visits (GBP 24,300 cost reimbursement for attendance). Six (30%) patients were readmitted on 9 occasions due to device malfunction or inability to cope at home.

CONCLUSION

Careful identification of patients suitable for discharge with a portable suction device achieved a significant cost-saving and freed hospital beds, thus allowing increased surgical activity. Patients were also able to be cared for within their home environment and maintain their quality of life.

Multiloculated pleural effusion detected by ultrasound only in a critically-ill patient

Background:

Multiloculated pleural effusion is a life-threatening condition that needs early recognition. Drainage by chest tube might be difficult which necessitates a surgical intervention. While x-ray typically does not show loculations, CT scan might not also identify the loculations. Ultrasound has a high sensitivity in detecting pleural diseases including multiloculated pleural effusion.

Case Report:

A 55-year-old female presented with dyspnea, cough and yellowish sputum for 3 days. Her heart rate was 136 bpm ,O2 saturation 88%, and WBC 21,000/mcL. Chest x-ray showed complete opacification of right lung. A chest tube insertion was unsuccessful. CT scan of the chest showed large pleural effusion occupying the right hemithorax with collapse of the right lung. Bedside ultra-sound showed a multiloculated pleural effusion with septations of different thickness. The patient subsequently underwent thoracotomy which showed multiple, fluid-filled loculations with significant adhesions. The loculations were dissected along with decortications of thick a pleural rind. Blood and pleural fluid cultures grew Streptococcus pneumoniae and the patient was treated successfully with Penicillin G.

Conclusions:

We advocate bedside ultrasound in patients with complete or near complete opacification of a hemithorax on chest x-ray. CT scan is less likely to show septations within pleural effusions compared to ultrasounnd. Therefore, CT scan and ultrasound are complementary for the diagnosis of empyema and multiloculated pleural effusion.

Bilateral pneumothoraces following a right subclavian catheter insertion after thymectomy for a patient with a myasthenic crisis

BACKGROUND

Myasthenia gravis (MG) is an autoimmune disease involving the formation of antibodies against the nicotinic acetylcholine receptors. Thymectomy is the treatment in MG patients with thymoma. We report a case of an MG patient who developed postthymectomy bilateral pneumothoraces after the placement of a subclavian central venous catheter.

CASE REPORT

The 21-year-old patient with MG underwent a thymectomy and, in a later admission, complained of myasthenic crisis symptoms. He was scheduled to receive plasma exchange therapy and electromyography the following day. Plasmapheresis was initiated after the placement of a right subclavian dialysis catheter. Postinsertion chest x-ray revealed bilateral pneumothoraces after a single unilateral attempt to cannulate the right subclavian vein. A right thoracotomy tube was placed with interval resolution of the bilateral pneumothoraces.

CONCLUSION

The development of bilateral pneumothoraces in this case was attributed to the possible accidental communication between the 2 pleural spaces, which rarely happens during thymectomy surgery.

Subxiphoid versus intercostal chest tubes: comparison of postoperative pain and pulmonary morbidities after coronary artery bypass grafting

Chest tubes are one cause of pain after cardiac surgery. In a prospective, randomized study, we investigated the effects of the position of chest tubes on acute postoperative pain and pulmonary morbidities in patients who underwent coronary artery bypass grafting. From June through December 2010, 40 patients who underwent elective coronary artery bypass grafting were enrolled in the study. We investigated 2 randomized groups of patients: Group 1 (n-20) had a left chest tube inserted through the midline inferior to the xiphoid process (subxiphoid approach), and Group 2 (n-20) had a left chest tube inserted through the 6th intercostal space along the anterior axillary line (intercostal approach). We compared the results with respect to postoperative pain, the need for analgesic agents, chest-tube drainage, pulmonary morbidities, and duration of hospitalization. The intensity of postoperative pain was similar between the groups. The cumulative doses of analgesic agents, incidence of pulmonary morbidities, and duration of hospitalization were also similar. Pleural effusion and atelectasis were each diagnosed in 3 patients in Group 1 (15%) and 1 patient in Group 2 (5%) (both P=0.68). Two of the patients in Group 1 required drainage of the pleural effusion. In our study, we found that the subxiphoid and intercostal approaches for chest-tube placement yielded similar clinical outcomes.

Use of a nasal speculum for chest-drain insertion: a simple technique

Tube thoracostomy is a very commonly performed procedure in cardiothoracic surgery. Insertion of a chest drain requires expertise to minimize complications. We describe a simple technique of using a nasal speculum to perform this procedure.

Spontaneous hemopneumothorax as a result of venous hemangioma: a unique case?

Spontaneous hemopneumothorax is a rare clinical entity that can be life-threatening, with a significant increase in mortality if not recognized and treated in time. We report the case of a young man who presented to us with nontraumatic spontaneous hemopneumothorax. Histologic examination of lung tissue showed the most likely cause of the bleeding to be venous hemangioma, which to the best of our knowledge has not been reported before.