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Bruck O, Naofal A, Senussi MH. Lung, Pleura, and Diaphragm Point-of-Care Ultrasound. Semin Ultrasound CT MR 2024; 45:120-131. [PMID: 38244897 DOI: 10.1053/j.sult.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
Thoracic Ultrasonography involves the ultrasonographic examination of the lungs, pleura, and diaphragm. This provides a plethora of clinical information during the point of care assessment of patients. The air filled lungs create consistent artifacts and careful examination and understanding of these artefactual signs can provide useful information on underlying clinicopathologic states. This review aims to provide a review of the ultrasound signs and features that can be seen in horacic ultrasonography and summarize the clinical evidence to support its use.
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Affiliation(s)
- Or Bruck
- Baylor College of Medicine, Houston, TX
| | | | - Mourad H Senussi
- Baylor College of Medicine, Houston, TX; Texas Heart Institute, Houston, TX.
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Bonaffini PA, Stanco F, Dulcetta L, Poli G, Brambilla P, Marra P, Valle C, Lorini FL, Mazzoleni M, Sonzogni B, Previdi F, Sironi S. Chest X-ray at Emergency Admission and Potential Association with Barotrauma in Mechanically Ventilated Patients: Experience from the Italian Core of the First Pandemic Peak. Tomography 2023; 9:2211-2221. [PMID: 38133075 PMCID: PMC10748272 DOI: 10.3390/tomography9060171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023] Open
Abstract
Barotrauma occurs in a significant number of patients with COVID-19 interstitial pneumonia undergoing mechanical ventilation. The aim of the current study was to investigate whether the Brixia score (BS) calculated on chest-X-rays acquired at the Emergency Room was associated with barotrauma. We retrospectively evaluated 117 SARS-CoV-2 patients presented to the Emergency Department (ED) and then admitted to the intensive care unit (ICU) for mechanical ventilation between February and April 2020. Subjects were divided into two groups according to the occurrence of barotrauma during their hospitalization. CXRs performed at ED admittance were assessed using the Brixia score. Distribution of barotrauma (pneumomediastinum, pneumothorax, subcutaneous emphysema) was identified in chest CT scans. Thirty-eight subjects (32.5%) developed barotrauma (25 pneumomediastinum, 24 pneumothorax, 24 subcutaneous emphysema). In the barotrauma group we observed higher Brixia score values compared to the non-barotrauma group (mean value 12.18 vs. 9.28), and logistic regression analysis confirmed that Brixia score is associated with the risk of barotrauma. In this work, we also evaluated the relationship between barotrauma and clinical and ventilatory parameters: SOFA score calculated at ICU admittance and number of days of non-invasive ventilation (NIV) prior to intubation emerged as other potential predictors of barotrauma.
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Affiliation(s)
- Pietro Andrea Bonaffini
- Department of Radiology, ASST Papa Giovanni XXIII, Piazza OMS, 24127 Bergamo, BG, Italy
- School of Medicine, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20126 Milan, MI, Italy
| | - Francesco Stanco
- Department of Radiology, ASST Papa Giovanni XXIII, Piazza OMS, 24127 Bergamo, BG, Italy
- School of Medicine, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20126 Milan, MI, Italy
| | - Ludovico Dulcetta
- Department of Radiology, ASST Papa Giovanni XXIII, Piazza OMS, 24127 Bergamo, BG, Italy
- School of Medicine, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20126 Milan, MI, Italy
| | - Giancarla Poli
- Unit of Intensive Care and Anesthesia 2, Papa Giovanni XXIII Hospital, Piazza OMS, 24127 Bergamo, BG, Italy
| | - Paolo Brambilla
- Department of Radiology, ASST Papa Giovanni XXIII, Piazza OMS, 24127 Bergamo, BG, Italy
| | - Paolo Marra
- Department of Radiology, ASST Papa Giovanni XXIII, Piazza OMS, 24127 Bergamo, BG, Italy
- School of Medicine, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20126 Milan, MI, Italy
| | - Clarissa Valle
- Department of Radiology, ASST Papa Giovanni XXIII, Piazza OMS, 24127 Bergamo, BG, Italy
- School of Medicine, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20126 Milan, MI, Italy
| | - Ferdinando Luca Lorini
- School of Medicine, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20126 Milan, MI, Italy
- Unit of Intensive Care and Anesthesia 2, Papa Giovanni XXIII Hospital, Piazza OMS, 24127 Bergamo, BG, Italy
| | - Mirko Mazzoleni
- Department of Management, Information and Production Engineering, University of Bergamo, Via Pasubio, 7/B, 24044 Dalmine, BG, Italy
| | - Beatrice Sonzogni
- Department of Management, Information and Production Engineering, University of Bergamo, Via Pasubio, 7/B, 24044 Dalmine, BG, Italy
| | - Fabio Previdi
- Department of Management, Information and Production Engineering, University of Bergamo, Via Pasubio, 7/B, 24044 Dalmine, BG, Italy
| | - Sandro Sironi
- Department of Radiology, ASST Papa Giovanni XXIII, Piazza OMS, 24127 Bergamo, BG, Italy
- School of Medicine, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20126 Milan, MI, Italy
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Goossen RL, Verboom M, Blacha M, Smesseim I, Beenen LFM, van Meenen DMP, Paulus F, Schultz MJ. Incidence of Air Leaks in Critically Ill Patients with Acute Hypoxemic Respiratory Failure Due to COVID-19. Diagnostics (Basel) 2023; 13:1156. [PMID: 36980464 PMCID: PMC10046975 DOI: 10.3390/diagnostics13061156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 03/30/2023] Open
Abstract
Subcutaneous emphysema, pneumothorax and pneumomediastinum are well-known complications of invasive ventilation in patients with acute hypoxemic respiratory failure. We determined the incidences of air leaks that were visible on available chest images in a cohort of critically ill patients with acute hypoxemic respiratory failure due to coronavirus disease of 2019 (COVID-19) in a single-center cohort in the Netherlands. A total of 712 chest images from 154 patients were re-evaluated by a multidisciplinary team of independent assessors; there was a median of three (2-5) chest radiographs and a median of one (1-2) chest CT scans per patient. The incidences of subcutaneous emphysema, pneumothoraxes and pneumomediastinum present in 13 patients (8.4%) were 4.5%, 4.5%, and 3.9%. The median first day of the presence of an air leak was 18 (2-21) days after arrival in the ICU and 18 (9-22)days after the start of invasive ventilation. We conclude that the incidence of air leaks was high in this cohort of COVID-19 patients, but it was fairly comparable with what was previously reported in patients with acute hypoxemic respiratory failure in the pre-COVID-19 era.
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Affiliation(s)
- Robin L. Goossen
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Mariëlle Verboom
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Mariëlle Blacha
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Illaa Smesseim
- Department of Thoracic Oncology, Antoni van Leeuwenhoek Ziekenhuis, 1066 CX Amsterdam, The Netherlands
| | - Ludo F. M. Beenen
- Department of Radiology, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - David M. P. van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- ACHIEVE, Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, 1091 GC Amsterdam, The Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
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Ikejiri K, Goto H, Usui M, Nakayama Y, Sugioka K, Ito A, Suzuki K, Hirokawa Y, Yamanaka K, Imai H. Septic pulmonary embolism and subsequent bilateral pneumothorax in patients undergoing chemoradiotherapy for head angiosarcoma: An autopsy case report and literature review. Medicine (Baltimore) 2022; 101:e31755. [PMID: 36397415 PMCID: PMC9666164 DOI: 10.1097/md.0000000000031755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
RATIONALE Septic pulmonary embolism (SPE) and subsequent pneumothorax are rare but serious conditions. We report a case of SPE and pneumothorax caused by central venous port (CV port) infection. PATIENT CONCERNS A 73-year-old woman, who underwent chemoradiotherapy for a head angiosarcoma and a CV port placement, presented with general malaise and myalgia. DIAGNOSIS A laboratory examination showed high levels of inflammatory markers. Chest computed tomography showed fluid collection around the CV port and multiple ground-glass opacities and nodular shadows in the bilateral lung field. She was admitted with a diagnosis of SPE due to CV port infection. The port was removed, and antibiotic administration was initiated; however, she was intubated because of refractory septic shock. Methicillin-susceptible Staphylococcus aureus was detected in the blood and pus around the port site. INTERVENTIONS Her respiratory status did not improve despite recovering from septic shock, and radiologic findings showed a left pneumothorax and exacerbation of SPE on day 9. Her condition was judged ineligible for surgery for pneumothorax, and chest tube thoracostomy was continued. OUTCOMES Air leaks persisted after chest tube thoracostomy, and her respiratory status did not improve despite ventilator management and recruitment maneuvers. Moreover, a right pneumothorax developed on day 19. Her respiratory status gradually worsened, and she died on day 21. Autopsy showed multiple cavitary lesions in the bilateral lungs and emboli containing organization and inflammatory cells that obstructed the pulmonary arterioles. LESSONS This case indicates that CV port-related infections are infrequent and difficult to diagnose; understanding the clinical features of SPE is important because of its high mortality rate; and pneumothorax secondary to SPE is a rare but serious condition and is difficult to treat during ventilator management.
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Affiliation(s)
- Kaoru Ikejiri
- Emergency and Critical Care Center, Mie University Hospital, Tsu City, Japan
- * Correspondence: Kaoru Ikejiri, Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu City, Mie 514-8507, Japan (e-mail: )
| | - Hiroyuki Goto
- Department of Dermatology, Mie University Graduate School of Medicine, Tsu City, Japan
| | - Miki Usui
- Department of Diagnostic Pathology, Mie University Hospital, Tsu City, Japan
| | - Yuichi Nakayama
- Department of Dermatology, Mie University Graduate School of Medicine, Tsu City, Japan
| | - Kyoko Sugioka
- Department of Dermatology, Mie University Graduate School of Medicine, Tsu City, Japan
| | - Asami Ito
- Emergency and Critical Care Center, Mie University Hospital, Tsu City, Japan
| | - Kei Suzuki
- Emergency and Critical Care Center, Mie University Hospital, Tsu City, Japan
- Department of Infectious Diseases, Mie University Hospital, Tsu City, Japan
| | - Yoshifumi Hirokawa
- Department of Diagnostic Pathology, Mie University Hospital, Tsu City, Japan
| | - Keiichi Yamanaka
- Department of Dermatology, Mie University Graduate School of Medicine, Tsu City, Japan
| | - Hiroshi Imai
- Emergency and Critical Care Center, Mie University Hospital, Tsu City, Japan
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Hafeez A, Nadeem N, Iqbal J, Qureshi A, Shakeel A, Zafar U. Concordance Between Resident and Attending Radiologist in Reporting Pneumothorax on Intensive Care Unit and Emergency Room Chest Radiographs. Cureus 2022; 14:e29672. [PMID: 36320981 PMCID: PMC9616555 DOI: 10.7759/cureus.29672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 11/14/2022] Open
Abstract
Introduction Pneumothorax is a common medical emergency and has potentially life-threatening consequences, so it is important for radiology residents and consultants to know its radiographic appearance so that timely diagnosis and appropriate management can be done. Patients with pneumothorax have nonspecific complaints, and clinical examinations are not confirmatory. The chest X-ray is easily available and has high accuracy in the detection of pneumothorax. The aim of this study is to determine the agreement between the on-call radiology resident and the attending radiologist in the diagnosis of pneumothorax on chest radiographs. Materials and methods This cross-sectional study was performed in the Department of Radiology at Aga Khan University Hospital, Karachi. After approval from the ethical review committee (ERC), the study was carried out. A total of 174 patients were included in the study. The resident interpreting the radiograph commented on the pneumothorax and recorded it on the “Comments” section of the picture archiving and communication system (PACS). Further entries were made in the department’s “Panic Logbook.” Subsequently, the final report by the attending radiologist was tallied, and the decision of both the resident and the attending radiologist regarding the presence or absence of pneumothorax was compared for interobserver agreement. Results Of the 174 patients, 139 (79.9%) were male and 35 (20.1%) were female. The mean age of the patients was 45.6 ± 12.4 years. Pneumothorax was reported by the resident in 164 (94.25%) cases, while the attending radiologist reported it in 167 (96%) cases. The remaining 4% of cases were ultimately diagnosed on a CT scan of the chest performed at the request of the primary team; they were too small to be detected on a chest radiograph. The most common side involved was the right side, with 112 (64.4%) cases, followed by the left side with 55 (31.6%) and both sides with five (2.9%), while in two cases, pneumothorax was not reported by the resident and the attending radiologist. The position of the pneumothorax was as follows: apex in 80 (46%), base in 56 (32.2%), and along the lateral border of the lung in 93 (53.4%). Concordance between the resident and the radiologist was found to be 92.5% (kappa = 0.20; p = 0.008). Stratification for age, gender, the position of pneumothorax, and the level of residency was also carried out. Conclusion In our setting, there was a high level of agreement (92.5%) between the resident and the attending radiologist in reporting pneumothorax on chest radiographs (kappa = 0.20; p = 0.008).
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Nguyen ET, Bayanati H, Hurrell C, Aitken M, Cheung EM, Gupta A, Harris S, Sedlic T, Taylor JL, Gahide G, Dennie C. Canadian Association of Radiologists/Canadian Association of Interventional Radiologists/Canadian Society of Thoracic Radiology Guidelines on Thoracic Interventions. Can Assoc Radiol J 2022; 74:272-287. [PMID: 36154303 DOI: 10.1177/08465371221122807] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Thoracic interventions are frequently performed by radiologists, but guidelines on appropriateness criteria and technical considerations to ensure patient safety regarding such interventions is lacking. These guidelines, developed by the Canadian Association of Radiologists, Canadian Association of Interventional Radiologists and Canadian Society of Thoracic Radiology focus on the interventions commonly performed by thoracic radiologists. They provide evidence-based recommendations and expert consensus informed best practices for patient preparation; biopsies of the lung, mediastinum, pleura and chest wall; thoracentesis; pre-operative lung nodule localization; and potential complications and their management.
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Affiliation(s)
- Elsie T Nguyen
- Joint Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Hamid Bayanati
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Casey Hurrell
- Canadian Association of Radiologists, Ottawa, ON, Canada
| | - Matthew Aitken
- Joint Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada,St. Michael's Hospital, University of Toronto, ON, Canada
| | - Edward M Cheung
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Ashish Gupta
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Scott Harris
- Health Sciences Centre, Memorial University of Newfoundland, St. John’s, NL, Canada
| | - Tony Sedlic
- Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Jana Lyn Taylor
- Department of Diagnostic Radiology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Gerald Gahide
- Service de radiologie interventionelle, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Carole Dennie
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada,Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Abdelghany Y, Rachmasari K, Alvarez-Mulett S, Wong R, Rajwani K. Incidence and management of pneumothorax, pneumomediastinum, and subcutaneous emphysema in COVID-19. SAGE Open Med 2022; 10:20503121221124761. [PMID: 36172565 PMCID: PMC9511305 DOI: 10.1177/20503121221124761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/17/2022] [Indexed: 01/08/2023] Open
Abstract
Objective The coronavirus disease 2019 (COVID-19) pandemic reached New York City in March 2020, leading to a state of emergency that affected many lives. Patients who contracted the disease presented with different phenotypes. Multiple reports have described the findings of computed tomography scans of these patients, several with pneumothoraces, pneumomediastinum, and subcutaneous emphysema. Our aim was to describe the incidence and management of pneumothorax, pneumomediastinum, and subcutaneous emphysema related to COVID-19 found on radiologic imaging. Methods A retrospective chart review was conducted of all confirmed COVID-19 patients admitted between early March and mid-May to two hospitals in New York City. Patient demographics, radiological imaging, and clinical courses were documented. Results Between early March and mid-May, a total of 1866 patients were diagnosed with COVID-19 in the two hospitals included in the study, of which 386 were intubated. The majority of these patients were men (1090, 58.4%). The distribution of comorbidities included the following: hypertension (1006, 53.9%), diabetes (544, 29.6%), and underlying lung disease (376, 20.6%). Among the 386 intubated patients, 65 developed study-specific complications, for an overall incidence of 16.8%; 36 developed a pneumothorax, 2 developed pneumomediastinum, 1 had subcutaneous emphysema, and 26 had a combination of both. The mean time of invasive ventilation was 14 days (0-46, interquartile range = 6-19, median 11). The average of highest positive end expiratory pressure within 72 h of study complication was 11 (5-24) cmH20. The average of the highest peak inspiratory pressure within 72 h of complication was 35.3 (17-52) cmH2O. In non-Intubated patients, 9/1480 had spontaneous pneumothorax, for an overall incidence of 0.61 %. Conclusion Intubated patients with COVID-19 pneumonia are at high risk of pneumothorax, pneumomediastinum, and subcutaneous emphysema. These should be considered in differential diagnosis of shortness of breath or hypoxia in a patient with a new diagnosis of COVID-19 or worsening hemodynamics or respiratory failure in an intensive care unit setting.
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Affiliation(s)
- Youmna Abdelghany
- Department of Internal Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Kharisa Rachmasari
- Department of Internal Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | | | - Rochelle Wong
- Department of Internal Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Kapil Rajwani
- Department of Internal Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
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Dubey R, Sen KK, Mishra A. Barotrauma and its complications in COVID-19 patients: a retrospective study at tertiary care hospital of Eastern India. BULLETIN OF THE NATIONAL RESEARCH CENTRE 2022; 46:212. [PMID: 35854795 PMCID: PMC9284477 DOI: 10.1186/s42269-022-00880-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 06/25/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The development of barotrauma in COVID-19 patients who were ventilated and admitted to the intensive treatment unit seemed to have been a problematic issue in the COVID era. This study aimed to explore the possibility of developing the barotrauma-related issues with mechanical ventilation in the cases of individuals suffering from COVID-19. RESULTS Out of 48 patients who developed barotrauma, 30 (62.5%) presented with pneumothorax, 22 (45.8%) with pneumomediastinum, 10 (20.8%) with subcutaneous emphysema, and 2 (4.1%) with pneumopericardium. Of those that developed barotrauma, 45 (93.7%) patients were in acute respiratory distress syndrome. In patients with and without barotrauma, significant factors were white blood cell count (p = 0.001), neutrophil percentage (p = 0.012), and lymphocyte percentage (p = 0.014). There were no statistically significant differences in CRP, procalcitonin, d-dimer test, LDH, or ferritin. CONCLUSIONS Patients infected with COVID-19 have a high risk of barotrauma when on mechanical ventilation. As a result, the death rate in this patient group is higher.
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Affiliation(s)
- Roopak Dubey
- Department of Radiodiagnosis, Kalinga Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha India
| | - Kamal Kumar Sen
- Department of Radiodiagnosis, Kalinga Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha India
| | - Aparajita Mishra
- Department of Community Medicine, Kalinga Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha India
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Characteristics and Factors Associated With Mortality in Patients With Coronavirus Disease 2019 and Pneumothorax. Mayo Clin Proc Innov Qual Outcomes 2022; 6:257-268. [PMID: 35495868 PMCID: PMC9040460 DOI: 10.1016/j.mayocpiqo.2022.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective To describe the incidence, clinical characteristics, and factors associated with mortality in patients hospitalized for coronavirus disease 2019 (COVID-19) in whom pneumothorax developed. Patients and Methods This study was a retrospective analysis conducted using a large administrative database of adult patients hospitalized for COVID-19 in the United States from February 1, 2020, to June 10, 2021. We characterized the clinical features of patients in whom pneumothorax developed and the factors associated with mortality and stratified pneumothorax by the timing of the initiation of invasive mechanical ventilation (IMV) and by the time of hospital admission (early versus late). Results A total of 811,065 adult patients had a positive test result for severe acute respiratory syndrome coronavirus 2, of whom 103,858 (12.8%) were hospitalized. Pneumothorax occurred in 1915 patients (0.24% overall and 1.84% among hospitalized patients). Over time, the use of steroids and remdesivir increased, whereas the use of IMV, pneumothorax rates, and mortality decreased. The clinical characteristics associated with pneumothorax were male sex; the receipt of IMV; and treatment with steroids, remdesivir, or convalescent plasma. Most patients with pneumothorax received IMV, but pneumothorax developed before the initiation of IMV and/or early during hospitalization in majority. Multivariable analysis revealed that pneumothorax increased the risk of death (adjusted hazard ratio [aHR], 1.15; 95% CI, 1.06-1.24). In patients who did not receive IMV, pneumothorax led to nearly twice the mortality (aHR, 1.99; 95% CI, 1.56-2.54). Increased mortality was also noted when pneumothorax occurred before IMV (aHR, 1.37; 95% CI, 1.11-1.69) and within 7 days of hospital admission (aHR, 1.60; 95% CI, 1.29-1.98). Conclusion The overall incidence of pneumothorax in patients hospitalized for COVID-19 was low. Pneumothorax is an independent risk factor for death.
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Umbrello M, Venco R, Antonucci E, Cereghini S, Filardo C, Guglielmetti L, Montanari G, Muttini S. Incidence, clinical characteristics and outcome of barotrauma in critically ill patients with COVID-19: a systematic review and meta-analysis. Minerva Anestesiol 2022; 88:706-718. [PMID: 35416463 DOI: 10.23736/s0375-9393.22.16258-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Barotrauma is rare in patients with acute respiratory distress syndrome undergoing mechanical ventilation. Its incidence seems increased among critically ill COVID-19 patients. We performed a systematic review and meta-analysis to investigate the incidence, risk factors and clinical outcomes of barotrauma among critically ill COVID-19 patients EVIDENCE ACQUISITION: PubMed was searched from March 1st, 2020 to August 31st, 2021; case series and retrospective cohort studies concerning barotrauma in adult critically ill COVID-19 patients, either hospitalized in the Intensive Care Unit (ICU) or invasively ventilated were included. Primary outcome was the incidence of barotrauma in COVID-19 versus non-COVID-19 patients. Secondary outcomes were clinical characteristics, ventilator parameters, mortality and length of stay between patients with and without barotrauma. EVIDENCE SYNTHESIS We identified 21 studies (six case series, 15 retrospective cohorts). The overall incidence of barotrauma was 11 [95% CI: 8-14]% in critically ill COVID-19 patients, vs. 2 [1-3]% in non-COVID-19, P<0.001; the incidence in mechanically ventilated patients was 14 [11-17]% vs. 4 [2-5]% non-COVID-19 patients, P<0.001. There were no differences in demographic, clinical, ventilatory parameters between patients who did and did not develop barotrauma, while, on average, protective ventilation criteria were always respected. Among COVID-19 patients, those with barotrauma had a higher mortality (60 [55-66] vs. 48 [42-54]%, P<0.001) and a longer ICU length of stay (20 [14-26] vs. 13 [10,5-16] days, P=0.03). CONCLUSIONS Barotrauma is a frequent complication in critically ill COVID-19 patients and is associated with a poor prognosis. Since lung protective ventilation was delivered, the ventilatory management might not be the sole factor in the development of barotrauma.
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Affiliation(s)
- Michele Umbrello
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy -
| | - Roberto Venco
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Edoardo Antonucci
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Sergio Cereghini
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Clelia Filardo
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Luigi Guglielmetti
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Giulia Montanari
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Stefano Muttini
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
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Tetaj N, Garotto G, Albarello F, Mastrobattista A, Maritti M, Stazi GV, Marini MC, Caravella I, Macchione M, De Angelis G, Busso D, Di Lorenzo R, Scarcia S, Farina A, Centanni D, Vargas J, Savino M, Carucci A, Antinori A, Palmieri F, D’Offizi G, Ianniello S, Taglietti F, Campioni P, Vaia F, Nicastri E, Girardi E, Marchioni L. Incidence of Pneumothorax and Pneumomediastinum in 497 COVID-19 Patients with Moderate-Severe ARDS over a Year of the Pandemic: An Observational Study in an Italian Third Level COVID-19 Hospital. J Clin Med 2021; 10:5608. [PMID: 34884310 PMCID: PMC8658701 DOI: 10.3390/jcm10235608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 11/25/2021] [Accepted: 11/27/2021] [Indexed: 01/12/2023] Open
Abstract
(1) Background: COVID-19 is a novel cause of acute respiratory distress syndrome (ARDS). Indeed, with the increase of ARDS cases due to the COVID-19 pandemic, there has also been an increase in the incidence of cases with pneumothorax (PNX) and pneumomediastinum (PNM). However, the incidence and the predictors of PNX/PMN in these patients are currently unclear and even conflicting. (2) Methods: The present observational study analyzed the incidence of barotrauma (PNX/PNM) in COVID-19 patients with moderate-severe ARDS hospitalized in a year of the pandemic, also focusing on the three waves occurring during the year, and treated with positive-pressure ventilation (PPV). We collected demographic and clinical data. (3) Results: During this period, 40 patients developed PNX/PNM. The overall incidence of barotrauma in all COVID-19 patients hospitalized in a year was 1.6%, and in those with moderate-severe ARDS in PPV was 7.2% and 3.8 events per 1000 positive-pressure ventilator days. The incidence of barotrauma in moderate-severe ARDS COVID-19 patients during the three waves was 7.8%, 7.4%, and 8.7%, respectively. Treatment with noninvasive respiratory support alone was associated with an incidence of barotrauma of 9.1% and 2.6 events per 1000 noninvasive ventilator days, of which 95% were admitted to the ICU after the event, due to a worsening of respiratory parameters. The incidence of barotrauma of ICU COVID-19 patients in invasive ventilation over a year was 5.8% and 2.7 events per 1000 invasive ventilator days. There was no significant difference in demographics and clinical features between the barotrauma and non-barotrauma group. The mortality was higher in the barotrauma group (17 patients died, 47.2%) than in the non-barotrauma group (170 patients died, 37%), although this difference was not statistically significant (p = 0.429). (4) Conclusions: The incidence of PNX/PNM in moderate-severe ARDS COVID-19 patients did not differ significantly between the three waves over a year, and does not appear to be very different from that in ARDS patients in the pre-COVID era. The barotrauma does not appear to significantly increase mortality in COVID-19 patients with moderate-severe ARDS if protective ventilation strategies are applied. Attention should be paid to the risk of barotrauma in COVID-19 patients in noninvasive ventilation because the event increases the probability of admission to the intensive care unit (ICU) and intubation.
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Affiliation(s)
- Nardi Tetaj
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Gabriele Garotto
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Fabrizio Albarello
- Department of Radiology and Diagnostic Imaging, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (F.A.); (S.I.); (P.C.)
| | - Annelisa Mastrobattista
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (A.M.); (F.P.)
| | - Micaela Maritti
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Giulia Valeria Stazi
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Maria Cristina Marini
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Ilaria Caravella
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Manuela Macchione
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Giada De Angelis
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Donatella Busso
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Rachele Di Lorenzo
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Silvana Scarcia
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Anna Farina
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Daniele Centanni
- Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (D.C.); (A.A.); (G.D.); (F.T.); (E.N.)
| | - Joel Vargas
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (J.V.); (M.S.)
| | - Martina Savino
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (J.V.); (M.S.)
| | - Alessandro Carucci
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Andrea Antinori
- Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (D.C.); (A.A.); (G.D.); (F.T.); (E.N.)
| | - Fabrizio Palmieri
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (A.M.); (F.P.)
| | - Gianpiero D’Offizi
- Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (D.C.); (A.A.); (G.D.); (F.T.); (E.N.)
| | - Stefania Ianniello
- Department of Radiology and Diagnostic Imaging, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (F.A.); (S.I.); (P.C.)
| | - Fabrizio Taglietti
- Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (D.C.); (A.A.); (G.D.); (F.T.); (E.N.)
| | - Paolo Campioni
- Department of Radiology and Diagnostic Imaging, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (F.A.); (S.I.); (P.C.)
| | - Francesco Vaia
- Health Direction, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy;
| | - Emanuele Nicastri
- Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (D.C.); (A.A.); (G.D.); (F.T.); (E.N.)
| | - Enrico Girardi
- Scientific Direction, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy;
| | - Luisa Marchioni
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
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Thachuthara-George J. Pneumothorax in patients with respiratory failure in ICU. J Thorac Dis 2021; 13:5195-5204. [PMID: 34527359 PMCID: PMC8411185 DOI: 10.21037/jtd-19-3752] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/24/2021] [Indexed: 11/15/2022]
Abstract
Pneumothorax is not an uncommon occurrence in ICU patients. Barotrauma and iatrogenesis remain the most common causes for pneumothorax in critically ill patients. Patients with underlying lung disease are more prone to develop pneumothorax, especially if they require positive pressure ventilation. A timely diagnosis of pneumothorax is critical as it may evolve into tension physiology. Most occurrences of pneumothoraces are readily diagnosed with a chest X-ray. Tension pneumothorax is a medical emergency, and managed with immediate needle decompression followed by tube thoracostomy. A computed tomography (CT) scan of the chest remains the gold standard for diagnosis; however, getting a CT scan of the chest in a critically ill patient can be challenging. The use of thoracic ultrasound has been emerging and is proven to be superior to chest X-ray in making a diagnosis. The possibility of occult pneumothorax in patients with thoracoabdominal blunt trauma should be kept in mind. Patients with pneumothorax in the ICU should be managed with a tube thoracostomy if they are symptomatic or on mechanical ventilation. The current guidelines recommend a small-bore chest tube as the first line management of pneumothorax. In patients with persistent air leak or whose lungs do not re-expand, a thoracic surgery consultation is recommended. In non-surgical candidates, bronchoscopic interventions or autologous blood patch are other options.
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Affiliation(s)
- Joseph Thachuthara-George
- Interventional Pulmonary Program, Division of Pulmonary, Allergy, and Critical Care Medicine, UAB, The University of Alabama at Birmingham, Birmingham, AL, USA
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13
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Serious complications in COVID-19 ARDS cases: pneumothorax, pneumomediastinum, subcutaneous emphysema and haemothorax. Epidemiol Infect 2021; 149:e137. [PMID: 34099076 PMCID: PMC8207553 DOI: 10.1017/s0950268821001291] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The novel coronavirus identified as severe acute respiratory syndrome-coronavirus-2 causes acute respiratory distress syndrome (ARDS). Our aim in this study is to assess the incidence of life-threatening complications like pneumothorax, haemothorax, pneumomediastinum and subcutaneous emphysema, probable risk factors and effect on mortality in coronavirus disease-2019 (COVID-19) ARDS patients treated with mechanical ventilation (MV). Data from 96 adult patients admitted to the intensive care unit with COVID-19 ARDS diagnosis from 11 March to 31 July 2020 were retrospectively assessed. A total of 75 patients abiding by the study criteria were divided into two groups as the group developing ventilator-related barotrauma (BG) (N = 10) and the group not developing ventilator-related barotrauma (NBG) (N = 65). In 10 patients (13%), barotrauma findings occurred 22 ± 3.6 days after the onset of symptoms. The mortality rate was 40% in the BG-group, while it was 29% in the NBG-group with no statistical difference identified. The BG-group had longer intensive care admission duration, duration of time in prone position and total MV duration, with higher max positive end-expiratory pressure (PEEP) levels and lower min pO2/FiO2 levels. The peak lactate dehydrogenase levels in blood were higher by statistically significant level in the BG-group (P < 0.05). The contribution of MV to alveolar injury caused by infection in COVID-19 ARDS patients may cause more frequent barotrauma compared to classic ARDS and this situation significantly increases the MV and intensive care admission durations of patients. In terms of reducing mortality and morbidity in these patients, MV treatment should be carefully maintained within the framework of lung-protective strategies and the studies researching barotrauma pathophysiology should be increased.
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Sami R, Sereshti N. Case Report: Barotrauma in COVID-19 Case Series. Am J Trop Med Hyg 2021; 105:54-58. [PMID: 34003793 PMCID: PMC8274782 DOI: 10.4269/ajtmh.21-0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/29/2021] [Indexed: 12/12/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 can cause pulmonary complications, such as increased risk of barotrauma (BT), but its prevalence and risk factors are not known. In this case series, the course of BT and its related risk factors were discussed in patients with COVID-19 who were admitted to the intensive care unit. Medical records of the patients with COVID-19 and BT and hospitalized in the intensive care unit for 5 months were extracted. The course of BT and its possible associated risk factors are descriptively presented. Among 103 patients with COVID-19 who were intubated, 13 patients (12.6%) had BT. One patient developed BT before intubation. All patients with BT were male. Half of them developed BT in the first 5 days of intubation. Eight patients (61.53%) had a positive culture for Klebsiella pneumoniae. Nine patients (69.9%) died. High positive end-expiratory pressure, coinfection with bacterial pneumonia, and history of lung disease may affect BT incidence. The treatment team should increase their upervision on the ventilator setting, especially in the first week of intubation.
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Affiliation(s)
- Ramin Sami
- 1Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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15
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Ron E, Alattar Z, Hoebee S, Kang P, vanSonnenberg E. Current Trends in the Use of Ultrasound Over Chest X-Ray to Identify Pneumothoraces in ICU, Trauma, and ARDS Patients. J Intensive Care Med 2021; 37:5-11. [PMID: 33611954 DOI: 10.1177/0885066620987813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pneumothoraces are a common and potentially fatal complication for critically ill patients in the trauma and intensive care units. Since its use for pneumothorax detection was first reported in 1987, ultrasound has been increasingly used for the detection of thoracic injuries. As ultrasound imaging has improved and operators have potentially become more proficient, it is important to analyze more recent trends in the sensitivities and specificities of ultrasound for the detection of pneumothorax. This literature review and meta-analysis identifies 17 studies that directly compare the sensitivity and specificity of ultrasound and anterior-posterior chest x-ray in the identification of pneumothorax among 2955 patients who developed 793 pneumothoraces as detected by gold standard CT scanning. For the 17 articles analyzed, the pooled sensitivity of trans-thoracic ultrasound was 75.07% (64.92%-85.22%), and the pooled specificity was 98.36% (97.45%-99.26%). The pooled sensitivity of CXR was 45.65% (36.04%-55.26%), and pooled specificity was 99.62% (99.00%-100%). While this review demonstrates an improved sensitivity in the detection of pneumothorax with ultrasound over AP chest x-rays, it did not find a significant trend or improvement in the sensitivity or specificity of ultrasound for detecting pneumothorax over time.
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Affiliation(s)
- Eyal Ron
- 42283University of Arizona College of Medicine-Phoenix, AZ, USA
| | - Zana Alattar
- 42283University of Arizona College of Medicine-Phoenix, AZ, USA
| | - Shelby Hoebee
- 42283University of Arizona College of Medicine-Phoenix, AZ, USA
| | - Paul Kang
- 42283University of Arizona College of Medicine-Phoenix, AZ, USA
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16
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Baek MS, Lee Y, Hong SB, Lim CM, Koh Y, Huh JW. Effect of corticosteroid therapy in the early phase of acute respiratory distress syndrome: a propensity-matched cohort study. Korean J Intern Med 2021; 36:145-153. [PMID: 32114751 PMCID: PMC7820645 DOI: 10.3904/kjim.2019.153] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 08/09/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/AIMS It is unclear whether corticosteroid use in patients with acute respiratory distress syndrome (ARDS) improves survival. This study aimed to investigate whether the administration of corticosteroids to patients in the early phase of moderate to severe ARDS is associated with improved outcomes. METHODS We analyzed the data of patients who received corticosteroids within 7 days of the onset of ARDS between June 2006 and December 2015 at a single tertiary teaching hospital. A total of 565 patients admitted with moderate to severe ARDS were eligible. The outcomes of patients treated with methylprednisolone 40 to 180 mg/day or equivalent (n = 404) were compared to those who did not receive steroids (n = 161). The primary and secondary outcomes were 28- and 90-day mortality rates, respectively. Propensity scores were used to adjust for baseline covariates. RESULTS The overall mortality at 28 days was not significantly different between the corticosteroid-treated and control groups (43.8% vs. 41%, p = 0.541). At 90 days, the overall mortality rate was higher in the corticosteroid-treated group than in the control group (59.2% vs. 48.4%, p = 0.021). However, on propensity score matching, corticosteroid therapy was not associated with a higher 28-day mortality rate (odds ratio, 1.031; 95% confidence interval, 0.657 to 1.618; p = 0.895) and 90 days (odds ratio, 1.435; 95% confidence interval, 0.877 to 2.348; p = 0.151). CONCLUSION Corticosteroid therapy was not associated with 28- or 90-day mortality in the early phase of moderate to severe ARDS on propensity score matching analysis.
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Affiliation(s)
- Moon Seong Baek
- Division of Pulmonary, Allergy and Critical Care Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Yunkyoung Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence to Jin Won Huh, M.D. Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3985 Fax: +82-2-3010-6968 E-mail:
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17
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Hussain A, Noorani A, Deshpande R, John L, Baghai M, Wendler O, Whitaker D, Khan H. Management of pneumothorax in mechanically ventilated COVID-19 patients: early experience. Interact Cardiovasc Thorac Surg 2020; 31:540-543. [PMID: 32865193 PMCID: PMC7499637 DOI: 10.1093/icvts/ivaa129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/08/2020] [Accepted: 06/17/2020] [Indexed: 02/04/2023] Open
Abstract
A significant proportion of patients infected with the novel coronavirus, now termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), require intensive care admission and subsequent mechanical ventilation. Pneumothorax, a potential fatal complication of mechanical ventilation, can further complicate the management of COVID-19 patients, whilst chest drain insertion may increase the risk of transmission of attending staff. We present a case series and a suggested best-practice protocol for how to manage and treat pneumothoraces in COVID-19 patients in an intensive care unit setting.
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Affiliation(s)
- Azhar Hussain
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Alia Noorani
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Ranjit Deshpande
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Lindsay John
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Max Baghai
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Olaf Wendler
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Donald Whitaker
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Habib Khan
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
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Leturia Etxeberria M, Biurrun Mancisidor MC, Ugarte Nuño A, Arenaza Choperena G, Mendoza Alonso M, Esnaola Albizu M, Serdio Mier A, Gredilla Sáenz M, Gomez Usabiaga V. Imaging Assessment of Ectopic Gas Collections. Radiographics 2020; 40:1318-1338. [DOI: 10.1148/rg.2020200028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Maria Leturia Etxeberria
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Maria Carmen Biurrun Mancisidor
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Ane Ugarte Nuño
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Gorka Arenaza Choperena
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Miguel Mendoza Alonso
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Maite Esnaola Albizu
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Alberto Serdio Mier
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - María Gredilla Sáenz
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Virginia Gomez Usabiaga
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
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Peña-López Y, Ramirez-Estrada S, Eshwara VK, Rello J. Limiting ventilator-associated complications in ICU intubated subjects: strategies to prevent ventilator-associated events and improve outcomes. Expert Rev Respir Med 2018; 12:1037-1050. [PMID: 30460868 DOI: 10.1080/17476348.2018.1549492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Intubation is required to maintain the airways in comatose patients and enhance oxygenation in hypoxemic or ventilation in hypercapnic subjects. Recently, the Centers of Disease Control (CDC) created new surveillance definitions designed to identify complications associated with poor outcomes. Areas covered: The new framework proposed by CDC, Ventilator-Associated Events (VAE), has a range of definitions encompassing Ventilator-Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or Possible Ventilator-Associated Pneumonia - suggesting replacing the traditional definitions of Ventilator-Associated Tracheobronchitis (VAT) and Ventilator-Associated Pneumonia (VAP). They focused more on oxygenation variations than on Chest-X rays or inflammatory biomarkers. This article will review the spectrum of infectious (VAP & VAT) complications, as well as the main non-infectious complications, namely pulmonary edema, acute respiratory distress syndrome (ARDS) and atelectasis. Strategies to limit these complications and improve outcomes will be presented. Expert commentary: Improving outcomes should be the objective of implementing bundles of prevention, based on risk factors amenable of intervention. Promotion of measures that reduce the exposition or duration of intubation should be a priority.
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Affiliation(s)
- Yolanda Peña-López
- a Pediatric Critical Care Department , Vall d'Hebron Barcelona Hospital Campus , Barcelona , Spain
| | | | - Vandana Kalwaje Eshwara
- c Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education , Manipal University , Manipal , India
| | - Jordi Rello
- d Clinical Research/epidemiology In Pneumonia & Sepsis , Vall d'Hebron Institut of Research & Centro de Investigacion Biomedica en Red (CIBERES) , Barcelona , Spain
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A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill. Intensive Care Med 2018; 44:742-759. [PMID: 29754308 DOI: 10.1007/s00134-018-5212-y] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/05/2018] [Indexed: 12/14/2022]
Abstract
Intravascular catheters are inserted into almost all critically ill patients. This review provides up-to-date insight into available knowledge on epidemiology and diagnosis of complications of central vein and arterial catheters in ICU. It discusses the optimal therapy of catheter-related infections and thrombosis. Prevention of complications is a multidisciplinary task that combines both improvement of the process of care and introduction of new technologies. We emphasize the main component of the prevention strategies that should be used in critical care and propose areas of future investigation in this field.
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Garg SK, Garg P, Anchan N, Jaiswal A. Iatrogenic Bilateral Simultaneous Pneumothorax: Call for Vigilance. Indian J Crit Care Med 2017; 21:607-609. [PMID: 28970663 PMCID: PMC5613615 DOI: 10.4103/ijccm.ijccm_108_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Iatrogenic pneumothorax refers to the pneumothorax generated after diagnostic or therapeutic procedure. We report the case of a 40-year-old male who had bilateral simultaneous iatrogenic pneumothorax with pneumomediastinum leading to cardiac arrest situation, due to wrong placement of nebulization kit in spontaneously breathing intubated patient. We report this case for its rarity, due to the critical importance of this cause as a etiology of bilateral simultaneous iatrogenic pneumothorax leading to cardiac arrest situation, and need to understand the importance of continuous training and stress of emergency environment.
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Affiliation(s)
- Sunil Kumar Garg
- Department of Critical Care Medicine, NMC Hospital, Dubai, United Arab Emirates
| | - Pragya Garg
- Department of Critical Care Medicine, NMC Hospital, Dubai, United Arab Emirates
| | - Nidhi Anchan
- Department of Critical Care Medicine, NMC Hospital, Dubai, United Arab Emirates
| | - Ashish Jaiswal
- Department of Critical Care Medicine, NMC Hospital, Dubai, United Arab Emirates
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Abstract
Pneumothorax is defined as the abnormal presence of air within the pleural space (cavity) that results in the partial or complete collapse of a lung. It can occur spontaneously or due to a traumatic event. Symptoms can vary from a nondescriptive complaint of shortness of breath or chest pain to complete cardiopulmonary collapse. Diagnosis is based on a combination of clinical suspicion along with supporting imaging studies. Treatment often involves surgical or nonsurgical approaches with goal to alleviate symptoms and prevent recurrence.
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El-Nawawy AA, Al-Halawany AS, Antonios MA, Newegy RG. Prevalence and risk factors of pneumothorax among patients admitted to a Pediatric Intensive Care Unit. Indian J Crit Care Med 2016; 20:453-8. [PMID: 27630456 PMCID: PMC4994124 DOI: 10.4103/0972-5229.188191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Pneumothorax should be considered a medical emergency and requires a high index of suspicion and prompt recognition and intervention. AIMS The objective of the study was to evaluate cases developing pneumothorax following admission to a Pediatric Intensive Care Unit (PICU) over a 5-year period. SETTINGS AND DESIGN Case notes of all PICU patients (n = 1298) were reviewed, revealing that 135 cases (10.4%) developed pneumothorax, and these were compared with those patients who did not. The most common tool for diagnosis used was chest X-ray followed by a clinical examination. SUBJECTS AND METHODS Case notes of 1298 patients admitted in PICU over 1-year study. RESULTS Patients with pneumothorax had higher mortality rate (P < 0.001), longer length of stay (P < 0.001), higher need for mechanical ventilation (MV) (P < 0.001), and were of younger age (P < 0.001), lower body weight (P < 0.001), higher pediatric index of mortality 2 score on admission (P < 0.001), higher pediatric logistic organ dysfunction score (P < 0.001), compared to their counterpart. Iatrogenic pneumothorax (IP) represented 95% of episodes of pneumothorax. The most common causes of IP were barotrauma secondary to MV, central vein catheter insertion, and other (69.6%, 13.2%, and 17.2%, respectively). Compared to ventilated patients without pneumothorax, ventilated patients who developed pneumothorax had a longer duration of MV care (P < 0.001) and higher nonconventional and high-frequency oscillatory ventilation settings (P < 0.001). CONCLUSIONS This study demonstrated that pneumothorax is common in Alexandria University PICU patients, especially in those on MV and emphasized the importance of the strict application of protective lung strategies among ventilated patients to minimize the risk of pneumothorax.
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Affiliation(s)
- Ahmed Ahmed El-Nawawy
- Pediatric Department, Pediatric Intensive Care Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Amina Sedky Al-Halawany
- Pediatric Department, Pediatric Intensive Care Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Manal Abdelmalik Antonios
- Pediatric Department, Pediatric Intensive Care Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Reem Gamal Newegy
- Pediatric Department, Pediatric Intensive Care Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Mojsic B, Mandras A, Sujica M, Vasiljevic S. Pneumothorax Related to Mechanical Ventilation: Silent Enemy. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2016. [DOI: 10.1515/sjecr-2016-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Pneumothorax is well known and described complication in intensive care unit patients (ICU). Incidence of this complication is higher in patients with underlying pathology. As it can be occult, it is of the most importance to think of it in patients on mechanical ventilation. In this case report we well present ventilator-related pneumothorax in infant: clinical presentation, diagnosis and management
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Affiliation(s)
- Branislav Mojsic
- The Institute for Health Protection of Mother and Child of Serbia “Dr Vukan Cupic” Belgrade, Serbia
| | - Ana Mandras
- The Institute for Health Protection of Mother and Child of Serbia “Dr Vukan Cupic” Belgrade, Serbia
| | - Maja Sujica
- The Institute for Health Protection of Mother and Child of Serbia “Dr Vukan Cupic” Belgrade, Serbia
| | - Sladjana Vasiljevic
- The Institute for Health Protection of Mother and Child of Serbia “Dr Vukan Cupic” Belgrade, Serbia
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Selvan K, Edriss H, Sigler M, Nugent KM. Complications and Resource Utilization Associated With Mechanical Ventilation in a Medical Intensive Care Unit in 2013. J Intensive Care Med 2016; 32:146-150. [PMID: 26474803 DOI: 10.1177/0885066615612413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Evolving strategies for ventilator management could reduce the frequency of complications, but there is limited information about complications in contemporary intensive care units. METHODS We retrospectively collected information about patient demographics, chest x-ray abnormalities, complications, including pneumothoraces, ventilator-associated events, self-extubation, and resource utilization in 174 patients who required mechanical ventilation in 2013. RESULTS The mean age was 57.8 ± 16.8 years, the number of ventilator days was 7.5 ± 7, and the overall in-hospital mortality was 32.2%. The mean fluid balance per day during the mechanical ventilation period was 1539 ± 1721 mL. Three (1.7%) patients developed pneumothoraces, and 5 patients required chest tubes. Twenty-five (14.4%) patients had ventilator-associated events. Ten patients had episodes of self-extubation, and 11 had episodes of failed extubation. Chest X-rays showed new or increasing infiltrates in 113 (64.9%) patients and new or increasing pleural effusions in 29 (16.7%) patients. These patients had 1.2 ± 0.4 X-rays per day on the ventilator, and they had 10.0 ± 9.4 arterial blood gases and 0.7 ± 0.7 central lines. CONCLUSION The frequency of ventilator-associated complications was low in this study. However, these patients frequently developed increasing infiltrates, and these outcomes need attention during patient management and are a potential focus for future studies.
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Affiliation(s)
- Kavitha Selvan
- 1 Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Hawa Edriss
- 1 Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Mark Sigler
- 1 Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kenneth M Nugent
- 1 Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Abstract
The intra- and inter-hospital patient transfer is an important aspect of patient care which is often undertaken to improve upon the existing management of the patient. It may involve transfer of patient within the same facility for any diagnostic procedure or transfer to another facility with more advanced care. The main aim in all such transfers is maintaining the continuity of medical care. As the transfer of sick patient may induce various physiological alterations which may adversely affect the prognosis of the patient, it should be initiated systematically and according to the evidence-based guidelines. The key elements of safe transfer involve decision to transfer and communication, pre-transfer stabilisation and preparation, choosing the appropriate mode of transfer, i.e., land transport or air transport, personnel accompanying the patient, equipment and monitoring required during the transfer, and finally, the documentation and handover of the patient at the receiving facility. These key elements should be followed in each transfer to prevent any adverse events which may severely affect the patient prognosis. The existing international guidelines are evidence based from various professional bodies in developed countries. However, in developing countries like India, with limited infrastructure, these guidelines can be modified accordingly. The most important aspect is implementation of these guidelines in Indian scenario with periodical quality assessments to improve the standard of care.
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Affiliation(s)
- Ashish Kulshrestha
- Department of Anaesthesia and Intensive Care, Vardan Multispecialty Hospital, Garhi Sikrod, NH-58, Meerut Road, Ghaziabad, Uttar Pradesh, India
| | - Jasveer Singh
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
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Knight PH, Maheshwari N, Hussain J, Scholl M, Hughes M, Papadimos TJ, Guo WA, Cipolla J, Stawicki SP, Latchana N. Complications during intrahospital transport of critically ill patients: Focus on risk identification and prevention. Int J Crit Illn Inj Sci 2016; 5:256-64. [PMID: 26807395 PMCID: PMC4705572 DOI: 10.4103/2229-5151.170840] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Intrahospital transportation of critically ill patients is associated with significant complications. In order to reduce overall risk to the patient, such transports should well organized, efficient, and accompanied by the proper monitoring, equipment, and personnel. Protocols and guidelines for patient transfers should be utilized universally across all healthcare facilities. Care delivered during transport and at the site of diagnostic testing or procedure should be equivalent to the level of care provided in the originating environment. Here we review the most common problems encountered during transport in the hospital setting, including various associated adverse outcomes. Our objective is to make medical practitioners, nurses, and ancillary health care personnel more aware of the potential for various complications that may occur during patient movement from the intensive care unit to other locations within a healthcare facility, focusing on risk reduction and preventive strategies.
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Affiliation(s)
- Patrick H Knight
- Temple University School of Medicine - St. Luke's University Hospital Campus, Bethlehem, Pennsylvania, USA
| | - Neelabh Maheshwari
- Temple University School of Medicine - St. Luke's University Hospital Campus, Bethlehem, Pennsylvania, USA
| | - Jafar Hussain
- Temple University School of Medicine - St. Luke's University Hospital Campus, Bethlehem, Pennsylvania, USA
| | - Michael Scholl
- Temple University School of Medicine - St. Luke's University Hospital Campus, Bethlehem, Pennsylvania, USA
| | - Michael Hughes
- Temple University School of Medicine - St. Luke's University Hospital Campus, Bethlehem, Pennsylvania, USA
| | - Thomas J Papadimos
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Weidun Alan Guo
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, The State University of New York (SUNY)-University at Buffalo, Buffalo, New York, USA
| | - James Cipolla
- Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Stanislaw P Stawicki
- Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Nicholas Latchana
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Ali AAER, El Wahsh RAER, Agha MAES, Tawadroos BB. Pressure regulated volume controlled ventilation versus synchronized intermittent mandatory ventilation in COPD patients suffering from acute respiratory failure. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2016. [DOI: 10.1016/j.ejcdt.2015.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Heavner JJ, Siner JM. Adverse Event Reporting and Quality Improvement in the Intensive Care Unit. Clin Chest Med 2015; 36:461-7. [PMID: 26304283 DOI: 10.1016/j.ccm.2015.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients in the intensive care unit are at high risk for experiencing adverse events and errors. The high-acuity health care needs of these vulnerable patients expose them to numerous medications, procedures, and health care providers. The occurrence of adverse events is associated with detriments to patient outcomes including increased mortality. Adverse event reporting is the most commonly used event-detection tool, but it should also be complimented with other tools such as trigger tools, chart review, and direct observation. Although adverse event reporting is essential for continuous improvement processes and is associated with improvements in safety culture, it remains significantly underutilized.
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Affiliation(s)
- Jason J Heavner
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - Jonathan M Siner
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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da Silva PSL, de Aguiar VE, Fonseca MCM. Iatrogenic pneumothorax in mechanically ventilated children: Incidence, risk factors and other outcomes. Heart Lung 2015; 44:238-42. [DOI: 10.1016/j.hrtlng.2015.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 01/09/2015] [Accepted: 01/10/2015] [Indexed: 10/24/2022]
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Timsit JF, Bouadma L, Mimoz O, Parienti JJ, Garrouste-Orgeas M, Alfandari S, Plantefeve G, Bronchard R, Troche G, Gauzit R, Antona M, Canet E, Bohe J, Herrault MC, Schwebel C, Ruckly S, Souweine B, Lucet JC. Jugular versus femoral short-term catheterization and risk of infection in intensive care unit patients. Causal analysis of two randomized trials. Am J Respir Crit Care Med 2014; 188:1232-9. [PMID: 24127770 DOI: 10.1164/rccm.201303-0460oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
RATIONALE When subclavian access is not possible, controversy exists between the internal jugular and femoral sites for the choice of central-venous access in intensive care unit patients. OBJECTIVES To compare infection and colonization rates of short-term jugular and femoral catheters. METHODS Using data from two multicenter studies, we compared femoral and internal jugular for the risks of catheter-related bloodstream infection, major catheter-related infection, and catheter-tip colonization. We also compared the rates of dressing disruption and skin colonization. We used marginal structural models with inverse probability of treatment weighting to adjust on indication bias. MEASUREMENTS AND MAIN RESULTS We included 2,128 patients (2,527 catheters and 19,481 catheter-days). We found no difference in catheter-related bloodstream infection (internal jugular 1.0 vs. femoral 1.1 per 1,000 catheter-days; hazard ratio [HR], 0.63 [0.25-1.63]; P = 0.34), major catheter-related infection (internal jugular 1.8 vs. femoral 1.4 per 1,000 catheter-days; HR, 0.91 [0.38-2.18]; P = 0.34), and colonization (internal jugular 11.6 vs. femoral 12.9 per 1,000 catheter-days; HR, 0.80 [0.25-1.63]; P = 0.15). However, colonization was higher with femoral for female (HR, 0.39 [0.24-0.63]; P < 0.001) and, at the significance limit, catheter maintained for more than 4 days (HR, 0.73 [0.53-1.01]; P = 0.05). The absence of benefit of internal jugular before Day 5 was related to a higher skin colonization at the internal jugular site for catheters removed before Day 5. After the fourth day, dressing disruption became more frequent with femoral catheters and may explain the subsequent risk of catheter colonization. Differences in cutaneous and catheter colonization between internal jugular and femoral was suppressed by the use of chlorhexidine-impregnated dressings. CONCLUSIONS Femoral and internal jugular accesses lead to similar risks of catheter infection. Internal jugular might be preferred for female, nonchlorhexidine-impregnated dressings users, and when catheters are left in place more than 4 days. Both sites are acceptable when a subclavian approach is not feasible. Clinical trial registered with www.clinicaltrials.gov (NCT00417235 and NCT01189682).
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Affiliation(s)
- Jean-François Timsit
- 1 Grenoble 1 (Joseph Fourier) University, U823 "Outcome of Cancers and Critical Illness," Albert Bonniot Institute, La Tronche, France
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Kosiak W. Sonography of iatrogenic pneumothorax in pediatric patients. J Ultrason 2013; 13:379-93. [PMID: 26675373 PMCID: PMC4579669 DOI: 10.15557/jou.2013.0041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 11/18/2013] [Accepted: 11/20/2013] [Indexed: 12/16/2022] Open
Abstract
Pneumothorax is defined as the presence of air in the pleural cavity. The incidence of iatrogenic pneumothorax in the pediatric population is 0.3–0.48 in 1000 patients. A conventional chest X-ray, in some cases supplemented with chest computed tomography, is a typical imaging examination used to confirm the diagnosis of pneumothorax. Within the last years, the relevance of transthoracic lung ultrasound in the diagnostic process of this disease entity has greatly increased. This is confirmed by the opinion of a group of experts in ultrasound lung imaging in patients in a life-threatening condition, who strongly recommend a transthoracic ultrasound examination for the diagnosis of pneumothorax in such patients. These data constituted the basis for initiating the prospective studies on the application of this method in pneumothorax diagnosis in patients of pediatric hematology and oncology wards.
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Affiliation(s)
- Wojciech Kosiak
- Pracownia Diagnostyki Ultrasonograficznej i Biopsyjnej przy Klinice Pediatrii, Hematologii i Onkologii, Gdański Uniwersytet Medyczny, Gdańsk, Polska
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McCutcheon L, Yelland M. Iatrogenic pneumothorax: safety concerns when using acupuncture or dry needling in the thoracic region. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/1743288x11y.0000000012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Safety of intrahospital transport in ventilated critically ill patients: a multicenter cohort study*. Crit Care Med 2013; 41:1919-28. [PMID: 23863225 DOI: 10.1097/ccm.0b013e31828a3bbd] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To describe intrahospital transport complications in critically ill patients receiving invasive mechanical ventilation. DESIGN Prospective multicenter cohort study. SETTING Twelve French ICUs belonging to the OUTCOMEREA study group. PATIENTS Patients older than or equal to 18 years old admitted in the ICU and requiring invasive mechanical ventilation between April 2000 and November 2010 were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Six thousand two hundred forty-two patients on invasive mechanical ventilation were identified in the OUTCOMEREA database. The statistical analysis included a description of demographic and clinical characteristics of the cohort, identification of risk factors for intrahospital transport and construction of an intrahospital transport propensity score, and an exposed/unexposed study to compare complication of intrahospital transport (excluding transport to the operating room) after adjustment on the propensity score, length of stay, and confounding factors on the day before intrahospital transport. Three thousand and six intrahospital transports occurred in 1,782 patients (28.6%) (1-17 intrahospital transports/patient). Transported patients had higher admission Simplified Acute Physiology Score II values (median [interquartile range], 51 [39-65] vs 46 [33-62], p < 10) and longer ICU stay lengths (12 [6-23] vs 5 [3-11] d, p < 10). Post-intrahospital transport complications were recorded in 621 patients (37.4%). We matched 1,659 intrahospital transport patients to 3,344 nonintrahospital transport patients according to the intrahospital transport propensity score and previous ICU stay length. After adjustment, intrahospital transport patients were at higher risk for various complications (odds ratio = 1.9; 95% CI, 1.7-2.2; p < 10), including pneumothorax, atelectasis, ventilator-associated pneumonia, hypoglycemia, hyperglycemia, and hypernatremia. Intrahospital transport was associated with a longer ICU length of stay but had no significant impact on mortality. CONCLUSIONS Intrahospital transport increases the risk of complications in ventilated critically ill patients. Continuous quality improvement programs should include specific procedures to minimize intrahospital transport-related risks.
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How Accurate Is Ultrasonography for Excluding Pneumothorax? Ann Emerg Med 2013; 61:207-8. [DOI: 10.1016/j.annemergmed.2012.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Revised: 06/24/2012] [Accepted: 07/09/2012] [Indexed: 01/14/2023]
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GALBOIS A, ZORZI L, MEURISSE S, KERNÉIS S, MARGETIS D, ALVES M, AIT-OUFELLA H, BAUDEL JL, OFFENSTADT G, MAURY E, GUIDET B. Outcome of spontaneous and iatrogenic pneumothoraces managed with small-bore chest tubes. Acta Anaesthesiol Scand 2012; 56:507-12. [PMID: 22191997 DOI: 10.1111/j.1399-6576.2011.02602.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Little is known about the efficacy of management of iatrogenic pneumothoraces with small-bore chest tubes. The aim of this study was to assess the outcome of iatrogenic pneumothoraces requiring drainage managed with a small-bore chest tube and to compare the results to spontaneous pneumothoraces treated in the same unit with the same device. The primary outcome was requirement of video-assisted thoracoscopic surgery for drainage failure; secondary outcomes were length of drainage and number of inserted chest tubes. METHODS Patients with pneumothorax admitted between 1997 and 2007 were retrospectively identified. Traumatic pneumothoraces and those occurring under mechanical ventilation were excluded. All pneumothoraces were drained using the same small-bore chest tube (8 French) according to our local protocol. RESULTS Five hundred sixty-one pneumothoraces were analysed, 431 (76.8%) were spontaneous pneumothoraces and 130 (23.2%) were iatrogenic. Iatrogenic pneumothoraces were associated with less requirement of video-assisted thoracoscopic surgery for drainage failure [adjusted odds ratio= 0.24 (0.04, 0.86)]. Length of drainage of iatrogenic pneumothoraces was longer than for primary spontaneous pneumothoraces (3.8 ± 3.1 vs. 2.7 ± 1.8 days, P < 0.001) and shorter than for secondary spontaneous pneumothoraces (4.6 ± 2.3 days, P = 0.004). Number of inserted chest tubes per patient was not significantly different according to pneumothoraces' aetiology. CONCLUSION Small-bore chest tubes are feasible for treatment of iatrogenic pneumothoraces and have a better rate of success and slightly longer drainage duration than when used for spontaneous pneumothoraces.
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Affiliation(s)
| | - L. ZORZI
- AP-HP; Hôpital Saint-Antoine, Service de Réanimation Médicale; Paris; France
| | | | | | | | | | | | - J.-L. BAUDEL
- AP-HP; Hôpital Saint-Antoine, Service de Réanimation Médicale; Paris; France
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Garrouste-Orgeas M, Philippart F, Bruel C, Max A, Lau N, Misset B. Overview of medical errors and adverse events. Ann Intensive Care 2012; 2:2. [PMID: 22339769 PMCID: PMC3310841 DOI: 10.1186/2110-5820-2-2] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 02/16/2012] [Indexed: 12/20/2022] Open
Abstract
Safety is a global concept that encompasses efficiency, security of care, reactivity of caregivers, and satisfaction of patients and relatives. Patient safety has emerged as a major target for healthcare improvement. Quality assurance is a complex task, and patients in the intensive care unit (ICU) are more likely than other hospitalized patients to experience medical errors, due to the complexity of their conditions, need for urgent interventions, and considerable workload fluctuation. Medication errors are the most common medical errors and can induce adverse events. Two approaches are available for evaluating and improving quality-of-care: the room-for-improvement model, in which problems are identified, plans are made to resolve them, and the results of the plans are measured; and the monitoring model, in which quality indicators are defined as relevant to potential problems and then monitored periodically. Indicators that reflect structures, processes, or outcomes have been developed by medical societies. Surveillance of these indicators is organized at the hospital or national level. Using a combination of methods improves the results. Errors are caused by combinations of human factors and system factors, and information must be obtained on how people make errors in the ICU environment. Preventive strategies are more likely to be effective if they rely on a system-based approach, in which organizational flaws are remedied, rather than a human-based approach of encouraging people not to make errors. The development of a safety culture in the ICU is crucial to effective prevention and should occur before the evaluation of safety programs, which are more likely to be effective when they involve bundles of measures.
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Affiliation(s)
- Maité Garrouste-Orgeas
- Réanimation médico-chirurgicale, Groupe Hospitalier Paris Saint Joseph, Paris, France
- Université Joseph Fourier, Unité INSERM, Epidémiologie des cancers et des maladies sévères, Institut Albert Bonniot, La Tronche, France
| | - François Philippart
- Réanimation médico-chirurgicale, Groupe Hospitalier Paris Saint Joseph, Paris, France
- Medicine Faculty, Université Paris Descartes, Paris, France
- Infection and Epidemiology department Pasteur Institut, Paris, France
| | - Cédric Bruel
- Réanimation médico-chirurgicale, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Adeline Max
- Réanimation médico-chirurgicale, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Nicolas Lau
- Réanimation médico-chirurgicale, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - B Misset
- Réanimation médico-chirurgicale, Groupe Hospitalier Paris Saint Joseph, Paris, France
- Medicine Faculty, Université Paris Descartes, Paris, France
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Day MW. On alert for iatrogenic pneumothorax. Nursing 2011; 41:66-67. [PMID: 21587023 DOI: 10.1097/01.nurse.0000396448.19994.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Michael W Day
- Providence Sacred Heart Medical Center and Children's Hospital, Spokane, Wash., USA
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Stefanidis K, Dimopoulos S, Nanas S. Basic principles and current applications of lung ultrasonography in the intensive care unit. Respirology 2011; 16:249-56. [PMID: 20969673 DOI: 10.1111/j.1440-1843.2010.01885.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Until recently, the sonographic visualization of pulmonary and pleural diseases was considered a poorly accessible method, due to the inability of sound to penetrate air-filled lung. Despite its limitations, lung ultrasonography is becoming an important diagnostic tool in a growing number of pathological situations such as pneumonia, atelectasis, interstitial-alveolar syndrome, pulmonary embolism, pneumothorax and pleural effusion. The low sensitivity of CXR and the difficulties of performing CT make this technique invaluable for bedside use in the intensive care unit. Lung ultrasonography is an easily repeatable and radiation-free technique, and therefore, an attractive imaging tool for use on a daily basis, especially in the management of critically ill patients.
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Pigtail catheter for the management of pneumothorax in mechanically ventilated patients. Am J Emerg Med 2010; 28:466-71. [PMID: 20466227 DOI: 10.1016/j.ajem.2009.01.033] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 01/16/2009] [Accepted: 01/27/2009] [Indexed: 01/12/2023] Open
Abstract
PURPOSE There has been a paucity of data regarding the efficacy and safety of small-bore chest tubes (pigtail catheter) for the management of pneumothorax in mechanically ventilated patients. METHODS We conducted a retrospective review of mechanically ventilated patients who underwent pigtail catheter drainage as their initial therapy for pneumothorax in the emergency department and intensive care unit from January 2004 through January 2007 in a university hospital. RESULTS Among the 62 enrolled patients, there were 41 men (66%) and 21 women (34%), with a mean age of 63.8 +/- 20.3 years. A total of 70 episodes of pneumothoraces occurred in the intensive care unit, and 48 episodes of pneumothoraces (68.6%) were successfully treated with pigtail catheters. The average duration of pigtail drainage was 5.9 days (1-27 days). No major complications occurred through use of this procedure, except for pleural infections (n = 3, 4.2%) and clogged tube (n = 1, 1.4%). Comparing the variables between the success and failure of pigtail treatment, the failure group had a significantly higher proportion of Fio(2) >60% requirement (45.5% vs. 14.6%, P = .005) and higher positive end-expiratory pressure levels (8.7 +/- 3.0 vs. 6.2+/- 2.3 mm Hg, P = .001) at the time of pneumothorax onset than the success group. Further comparing the efficacy of pigtail drainage between barotraumas and iatrogenic pneumothorax, pigtail catheters for management of iatrogenic pneumothorax had a significantly higher success rate than barotraumas (87.5% vs. 43.3%, P < .0001). CONCLUSION Pigtail catheter drainage is relatively effective in treating iatrogenic but less promising for barotraumatic pneumothoraces.
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Garrouste-Orgeas M, Timsit JF, Vesin A, Schwebel C, Arnodo P, Lefrant JY, Souweine B, Tabah A, Charpentier J, Gontier O, Fieux F, Mourvillier B, Troché G, Reignier J, Dumay MF, Azoulay E, Reignier B, Carlet J, Soufir L. Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II. Am J Respir Crit Care Med 2009; 181:134-42. [PMID: 19875690 DOI: 10.1164/rccm.200812-1820oc] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
RATIONALE Although intensive care units (ICUs) were created for patients with life-threatening illnesses, the ICU environment generates a high risk of iatrogenic events. Identifying medical errors (MEs) that serve as indicators for iatrogenic risk is crucial for purposes of reporting and prevention. OBJECTIVES We describe the selection of indicator MEs, the incidence of such MEs, and their relationship with mortality. METHODS We selected indicator MEs using Delphi techniques. An observational prospective multicenter cohort study of these MEs was conducted from March 27 to April 3, 2006, in 70 ICUs; 16 (23%) centers were audited. Harm from MEs was collected using specific scales. MEASUREMENTS AND MAIN RESULTS Fourteen types of MEs were selected as indicators; 1,192 MEs were reported for 1,369 patients, and 367 (26.8%) patients experienced at least 1 ME (2.1/1,000 patient-days). The most common MEs were insulin administration errors (185.9/1,000 d of insulin treatment). Of the 1,192 medical errors, 183 (15.4%) in 128 (9.3%) patients were adverse events that were followed by one or more clinical consequences (n = 163) or that required one or more procedures or treatments (n = 58). By multivariable analysis, having two or more adverse events was an independent risk factor for ICU mortality (odds ratio, 3.09; 95% confidence interval, 1.30-7.36; P = 0.039). CONCLUSIONS The impact of medical errors on mortality indicates an urgent need to develop prevention programs. We have planned a study to assess a program based on our results.
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Affiliation(s)
- Maité Garrouste-Orgeas
- Service de Réanimation Médico-Chirurgicale, Groupe Hospitalier Paris Saint Joseph, 185 rue Raymond Losserand, 75014 Paris, France.
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Iatrogenic tension pneumothorax in children: two case reports. J Med Case Rep 2009; 3:7390. [PMID: 19830199 PMCID: PMC2726562 DOI: 10.4076/1752-1947-3-7390] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 01/29/2009] [Indexed: 11/08/2022] Open
Abstract
Introduction Two cases of iatrogenic tension pneumothorax in children are reported. Case presentations Case 1: A 2-year-old boy with suspected brain death after suffering multiple trauma suddenly developed intense cyanosis, extreme bradycardia and generalized subcutaneous emphysema during apnea testing. He received advanced cardiopulmonary resuscitation and urgent bilateral needle thoracostomy. Case 2: A diagnostic-therapeutic flexible bronchoscopy was conducted on a 17-month-old girl, under sedation-analgesia with midazolam and ketamine. She very suddenly developed bradycardia, generalized cyanosis and cervical, thoracic and abdominal subcutaneous emphysema. Urgent needle decompression of both hemithoraces was performed. Conclusion In techniques where gas is introduced into a child's airway, it is vital to ensure its way out to avoid iatrogenic tension pneumothorax. Moreover, the equipment to perform an urgent needle thoracostomy should be readily available.
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Kopterides P, Siempos II, Armaganidis A. Prone positioning in hypoxemic respiratory failure: meta-analysis of randomized controlled trials. J Crit Care 2009; 24:89-100. [PMID: 19272544 DOI: 10.1016/j.jcrc.2007.12.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Accepted: 12/28/2007] [Indexed: 02/07/2023]
Abstract
PURPOSE Prone positioning is used to improve oxygenation in patients with hypoxemic respiratory failure (HRF). However, its role in clinical practice is not yet clearly defined. The aim of this meta-analysis was to assess the effect of prone positioning on relevant clinical outcomes, such as intensive care unit (ICU) and hospital mortality, days of mechanical ventilation, length of stay, incidence of ventilator-associated pneumonia (VAP) and pneumothorax, and associated complications. METHODS We used literature search of MEDLINE, Current Contents, and Cochrane Central Register of Controlled Trials. We focused only on randomized controlled trials reporting clinical outcomes in adult patients with HRF. Four trials met our inclusion criteria, including 662 patients randomized to prone ventilation and 609 patients to supine ventilation. RESULTS The pooled odds ratio (OR) for the ICU mortality in the intention-to-treat analysis was 0.97 (95% confidence interval [CI], 0.77-1.22), for the comparison between prone and supine ventilated patients. Interestingly, the pooled OR for the ICU mortality in the selected group of the more severely ill patients favored prone positioning (OR, 0.34; 95% CI, 0.18-0.66). The duration of mechanical ventilation and the incidence of pneumothorax were not different between the 2 groups. The incidence of VAP was lower but not statistically significant in patients treated with prone positioning (OR, 0.81; 95% CI, 0.61-1.10). However, prone positioning was associated with a higher risk of pressure sores (OR, 1.49; 95% CI, 1.17-1.89) and a trend for more complications related to the endotracheal tube (OR, 1.30; 95% CI, 0.94-1.80). CONCLUSIONS Despite the inherent limitations of the meta-analytic approach, it seems that prone positioning has no discernible effect on mortality in patients with HRF. It may decrease the incidence of VAP at the expense of more pressure sores and complications related to the endotracheal tube. However, a subgroup of the most severely ill patients may benefit most from this intervention.
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Affiliation(s)
- Petros Kopterides
- 2nd Critical Care Department, University of Athens Medical School, Attiko University Hospital, Athens 12462, Greece.
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Costa ELV, Chaves CN, Gomes S, Beraldo MA, Volpe MS, Tucci MR, Schettino IAL, Bohm SH, Carvalho CRR, Tanaka H, Lima RG, Amato MBP. Real-time detection of pneumothorax using electrical impedance tomography. Crit Care Med 2008; 36:1230-8. [PMID: 18379250 DOI: 10.1097/ccm.0b013e31816a0380] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Pneumothorax is a frequent complication during mechanical ventilation. Electrical impedance tomography (EIT) is a noninvasive tool that allows real-time imaging of regional ventilation. The purpose of this study was to 1) identify characteristic changes in the EIT signals associated with pneumothoraces; 2) develop and fine-tune an algorithm for their automatic detection; and 3) prospectively evaluate this algorithm for its sensitivity and specificity in detecting pneumothoraces in real time. DESIGN Prospective controlled laboratory animal investigation. SETTING Experimental Pulmonology Laboratory of the University of São Paulo. SUBJECTS Thirty-nine anesthetized mechanically ventilated supine pigs (31.0 +/- 3.2 kg, mean +/- SD). INTERVENTIONS In a first group of 18 animals monitored by EIT, we either injected progressive amounts of air (from 20 to 500 mL) through chest tubes or applied large positive end-expiratory pressure (PEEP) increments to simulate extreme lung overdistension. This first data set was used to calibrate an EIT-based pneumothorax detection algorithm. Subsequently, we evaluated the real-time performance of the detection algorithm in 21 additional animals (with normal or preinjured lungs), submitted to multiple ventilatory interventions or traumatic punctures of the lung. MEASUREMENTS AND MAIN RESULTS Primary EIT relative images were acquired online (50 images/sec) and processed according to a few imaging-analysis routines running automatically and in parallel. Pneumothoraces as small as 20 mL could be detected with a sensitivity of 100% and specificity 95% and could be easily distinguished from parenchymal overdistension induced by PEEP or recruiting maneuvers. Their location was correctly identified in all cases, with a total delay of only three respiratory cycles. CONCLUSIONS We created an EIT-based algorithm capable of detecting early signs of pneumothoraces in high-risk situations, which also identifies its location. It requires that the pneumothorax occurs or enlarges at least minimally during the monitoring period. Such detection was operator-free and in quasi real-time, opening opportunities for improving patient safety during mechanical ventilation.
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Affiliation(s)
- Eduardo L V Costa
- Respiratory Intensive Care Unit, University of São Paulo School of Medicine, Brazil
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Powner D. Advanced practice organ procurement techniques: insertion of thoracic catheters. Prog Transplant 2007. [DOI: 10.7182/prtr.17.1.y516k4036235r258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Powner DJ. Advanced Practice Organ Procurement Techniques: Insertion of Thoracic Catheters. Prog Transplant 2007; 17:23-8. [PMID: 17484241 DOI: 10.1177/152692480701700103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Advanced practice coordinators who perform procedures that may be associated with complications must be proficient at treating those untoward events. This discussion reviews the diagnosis of a pneumothorax as a complication of insertion of a central venous catheter and mechanical ventilation. The method for inserting the Wayne Pneumothorax Set thoracic catheter is presented. This and similar commercially available catheters may also be used to evacuate a pleural effusion or nonclotted blood from the thorax for diagnostic purposes or when treating hypoxemia. It is essential for organ procurement organizations to provide appropriate training and quality assurance programs to ensure safe practice.
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Affiliation(s)
- David J Powner
- Department of Neurosurgery, University of Texas Health Science Center at Houston, USA
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Abstract
Violent trauma and road traffic injuries kill more than 2.5 million people in the world every year, for a combined mortality of 48 deaths per 100,000 population per year. Most trauma deaths occur at the scene or in the first hour after trauma, with a proportion from 34% to 50% occurring in hospitals. Preventability of trauma deaths has been reported as high as 76% and as low as 1% in mature trauma systems. Critical care errors may occur in a half of hospital trauma deaths, in most of the cases contributing to the death. The most common critical care errors are related to airway and respiratory management, fluid resuscitation, neurotrauma diagnosis and support, and delayed diagnosis of critical lesions. A systematic approach to the trauma patient in the critical care unit would avoid errors and preventable deaths.
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Affiliation(s)
- Alberto Garcia
- Trauma Division, Hospital Universitario del Valle, Calle 5 No. 36-08, Cali, Columbia.
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