Application of flexible bronchoscopy in inhalation lung injury

Feasibility of using red cell distribution width for prediction of postoperative mortality in severe burn patients: an association with acute kidney injury after surgery

BACKGROUND

Severe burns cause pathophysiological processes that result in mortality. A laboratory biomarker, red cell distribution width (RDW), is known as a predictor of mortality in critically-ill patients. We examined the association between RDW and postoperative mortality in severe burn patients.

METHODS

We retrospectively analyzed medical data of 731 severely burned patients who underwent surgery under general anesthesia. We evaluated whether preoperative RDW value can predict 3-month mortality after burn surgery using receiver operating characteristic (ROC) curve analysis, logistic regression, and Cox proportional-hazards regression analysis. Mortality was also analyzed according to preoperative RDW values and incidence of postoperative acute kidney injury (AKI).

RESULTS

The 3-month mortality rate after burn surgery was 27.1% (198/731). The area under the ROC curve of preoperative RDW to predict mortality after burn surgery was 0.701 (95% confidence interval [CI], 0.667-0.734; P < 0.001) with a cut-off point of 12.9. The adjusted hazard ratio in patients with RDW > 12.9 was 1.238 (95% CI, 1.138-1.347; P < 0.001). Subgroup analysis showed that the survival rate was 88.8% for the non-AKI group with RDW ≤ 12.9 and 17.6% for the AKI group with RDW > 12.9. Preoperative RDW was considered an independent risk factor for mortality (odds ratio, 1.679; 95% CI, 1.378- 2.046; P < 0.001).

CONCLUSIONS

Preoperative RDW may predict 3-month postoperative mortality in patients with severe burns, while preoperative RDW > 12.9 and postoperative AKI may further increase mortality after burn surgery.

A Rare Mechanism of Inhalation Injury: Direct Thermal Damage to the Lower Airway

In patients with inhalation injury associated with major burns, the primary mechanism of tissue harm depends on the location within the respiratory tract. Proximal to the trachea, the upper respiratory tract epithelium is classically injured via direct thermal injury. Such injury occurs due to the inhalation of high-temperature air. These upper airway structures and the tracheobronchial tree's dense vasculature protect the lower airways and lung parenchyma from direct thermal damage. The lower respiratory tract epithelium and lung parenchyma typically become injured secondary to the cytotoxic effects of chemical irritants inhaled in smoke as well as delayed inflammatory host responses. This paper documents a rare case in which a patient demonstrated evidence of direct thermal injury to the lower respiratory tract epithelium. A 26-year-old Caucasian male presented to the emergency room with 66% total body surface area thermal burns and grade 4 inhalation injury after a kitchen fire. Instead of visualizing carbonaceous deposits in the bronchi, a finding common in inhalation injury, initial bronchoscopy revealed bronchial mucosa carpeted with hundreds of bullae. Despite the maximum grade of inhalation injury per the abbreviated injury score and a 100% chance of mortality predicted with the revised Baux score, as well as a clinical course complicated by pneumonia development, bacteremia, and polymicrobial external wound infection, this patient survived. This dissonance between his expected and observed clinical outcome suggests that the applicability of current inhalation injury classification systems depends on the precise mechanism of injury to the respiratory tract. The flaws of these grading scales and prognostic indicators may be rooted in their failure to account for other pathophysiologic processes involved in inhalation injury. It may be necessary to develop new grading and prognostic systems for inhalation injury that acknowledge and better account for unusual pathophysiologic mechanisms of tissue damage.

A Case of Esophago-Respiratory Fistula due to Inhalation Smoke Injury Diagnosed by Upper Endoscopy

Esophago-respiratory fistula (ERF) refers to the formation of a pathological connection between the esophagus and respiratory tract. Acquired ERF is a rare but life-threatening diagnosis in adults. We describe a 79-year-old male who was admitted with an inhalation smoke injury. He was diagnosed with ERF by endoscopic visualization and sampling of the hyaline cartilage within the wall of the esophagus. Percutaneous endoscopic gastrostomy placement and conservative measures were effective in the management of ERF.

Temperature processing and distribution in larynx thermal inhalation injury with analogy to human airway cells: a mechanism of protection

OBJECTIVE

Inhalation injuries, especially laryngeal injuries, threaten the lives of burn patients. Unlike studies on temperature distribution in the upper airway, studies on temperature development in different laryngeal layers, including the mucosa, lamina propria, cartilage, muscle, and subcutaneous layer, are lacking.

METHOD

For the in-vivo study, 16 healthy adult male beagles were divided into four groups: control, low-, medium-, and high-heat groups, inhaling dry air at 26, 80, 160, and 320°C for 20 min, with temperature probes punctured through skin into layers as mentioned, and heat energy was calculated. For the in-vitro study, we heated human lung fibroblasts and bronchial epithelial cells using a similar heating profile with heat energy of 15-90 J/g to investigate cell survival and viability for clinical comparison.

RESULTS

No statistical difference emerged between the temperatures of different laryngeal layers at each timepoint. The temperatures decreased significantly and shortly before increasing unevenly in the low- and medium-heat groups. The survival rates and viability of the two cell lines correlated negatively with heat energy. The heat energy absorbed in the low-, medium-, and high-heat groups of beagles were 12, 29, and 44 J/g, with calculated in-vitro human cell survival rates of 114%, 90%, and 69%, respectively, for the corresponding energy levels.

CONCLUSIONS

The abnormal temperature processing and lack of a difference between layers indicate an effective self-protective mechanism of heat conduction in larynx. The in-vitro results demonstrate a high survival rate of lung cells at comparable heat energy levels to those measured in the larynx.

Positive signs on physical examination are not always indications for endotracheal tube intubation in patients with facial burn

Background

After clinical evaluation in the emergency department (ED), facial burn patients are usually intubated to protect their airways. However, the possibility of unnecessary intubation or delayed intubation after admission exists. Objective criteria for the evaluation of inhalation injury and the need for airway protection in facial burn patients are needed.

Methods

Facial burn patients between January 2013 and May 2016 were reviewed. Patients who were and were not intubated in the ED were compared. All the intubated patients received routine bronchoscopy and laboratory tests to evaluate whether they had inhalation injuries. The patients with and without confirmed inhalation injuries were compared. Multivariate logistic regression analysis was used to identify the independent risk factors for inhalation injuries in the facial burn patients. The reasons for intubation in the patients without inhalation injuries were also investigated.

Results

During the study period, 121 patients were intubated in the ED among a total of 335 facial burn patients. Only 73 (60.3%) patients were later confirmed to have inhalation injuries on bronchoscopy. The comparison between the patients with and without inhalation injuries showed that shortness of breath (odds ratio = 3.376, p = 0.027) and high total body surface area (TBSA) (odds ratio = 1.038, p = 0.001) were independent risk factors for inhalation injury. Other physical signs (e.g., hoarseness, burned nostril hair, etc.), laboratory examinations and chest X-ray findings were not predictive of inhalation injury in facial burn patients. All the patients with a TBSA over 60% were intubated in the ED even if they did not have inhalation injuries.

Conclusions

In the management of facial burn patients, positive signs on conventional physical examinations may not always be predictive of inhalation injury and the need for endotracheal tube intubation in the ED. More attention should be given to facial burn patients with shortness of breath and a high TBSA. Airway protection is needed in facial burn patients without inhalation injuries because of their associated injuries and treatments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00594-9.

Laryngeal inhalational injuries: A systematic review

Laryngeal inhalation injury carries a significant increase in mortality rate and often indicates immediate airway evaluation. This may be difficult in the setting of clinical deterioration necessitating immediate intubation, which itself can synergistically cause mucosal damage. Prior studies do not encompass predictive factors or long-term outcomes for the laryngotracheal complex. This systemic review of PubMed, Embase, and Cochrane identified studies investigating inhalational injuries of the upper airway. Demographic data as well as presentation, physical findings, and delayed sequelae were documented. Laryngotracheal burn patients were divided into two cohorts based on timing of laryngeal injury diagnosis (before- versus after-airway intervention). 1051 papers met initial search criteria and 43 studies were ultimately included. Airway stenosis was more common in patients that were intubated immediately (50.0%, n = 18 versus 5.2%, n = 13; p = 0.57). Posterior glottic involvement was only identified in patients intubated prior to airway evaluation (71.4%, n = 15). All studies reported a closed space setting for those patients in whom airway intervention preceded laryngeal evaluation. Laryngeal inhalational injuries are a distinct subset that can have a variety of minor to severe laryngotracheal delayed sequelae, particularly for thermal injuries occurring within enclosed spaces. Given these findings, early otolaryngology referral may mitigate or treat these effects.

Baseline Characteristics and Outcomes of Patients with Head and Neck Burn Injuries; a Cross-Sectional Study of 2181 Cases

INTRODUCTION

Despite recent progress in treatment of burn injuries, head and neck burn and its complications is still considered a challenge. This study aimed to evaluate the baseline characteristics and outcomes of patients with head and neck burn.

METHODS

In this retrospective cross-sectional study, the medical profiles of patients with head and neck burn referring to a burn care center during 2 years were reviewed and analyzed regarding the baseline characteristics and outcomes of participants.

RESULTS

392 (17.97%) cases suffered from head and neck burns. The mean burn percentage of participants was 29.31 ± 24.78, and 126 (32.14%) cases required tracheal intubation. There was a direct correlation between length of hospital stay and the degree of burn (p < 0.001). The length of hospitalization for patients burned by electricity was longer than those burned by other mechanisms (p = 0.003). There was a significant correlation between degree of burn and abnormal laryngoscopy findings (p = 0.036), developing acute respiratory distress syndrome (ARDS) (p < 0.001) and pneumonia (p < 0.001), need for mechanical ventilation (p < 0.001), and mortality rate (p < 0.001).

CONCLUSION

Based on the findings of the present study, the prevalence of head and neck burn injuries was about 18% and 32.14% of these cases required airway management. 19 (4.85%) cases developed ARDS, 41 (10.46%) developed pneumonia, and 50 (12.76%) cases died. There was a significant correlation between degree of burn and abnormal laryngoscopy findings, developing ARDS and pneumonia, need for mechanical ventilation, and mortality rate.

Baseline Characteristics and Outcomes of Patients with Head and Neck Burn Injuries; a Cross-Sectional Study of 2181 Cases

INTRODUCTION

Despite recent progress in treatment of burn injuries, head and neck burn and its complications is still considered a challenge. This study aimed to evaluate the baseline characteristics and outcomes of patients with head and neck burn.

METHODS

In this retrospective cross-sectional study, the medical profiles of patients with head and neck burn referring to a burn care center during 2 years were reviewed and analyzed regarding the baseline characteristics and outcomes of participants.

RESULTS

392 (17.97%) cases suffered from head and neck burns. The mean burn percentage of participants was 29.31 ± 24.78, and 126 (32.14%) cases required tracheal intubation. There was a direct correlation between length of hospital stay and the degree of burn (p < 0.001). The length of hospitalization for patients burned by electricity was longer than those burned by other mechanisms (p = 0.003). There was a significant correlation between degree of burn and abnormal laryngoscopy findings (p = 0.036), developing acute respiratory distress syndrome (ARDS) (p < 0.001) and pneumonia (p < 0.001), need for mechanical ventilation (p < 0.001), and mortality rate (p < 0.001).

CONCLUSION

Based on the findings of the present study, the prevalence of head and neck burn injuries was about 18% and 32.14% of these cases required airway management. 19 (4.85%) cases developed ARDS, 41 (10.46%) developed pneumonia, and 50 (12.76%) cases died. There was a significant correlation between degree of burn and abnormal laryngoscopy findings, developing ARDS and pneumonia, need for mechanical ventilation, and mortality rate.

An update on the role of bronchoscopy in the diagnosis of pulmonary disease

Bronchoscopy has evolved over the past few decades and has been used by respiratory physicians to diagnose various airway and lung diseases. With the popularization of medical check-ups and growing interest in health, early diagnosis of lung diseases is essential. With the development of endobronchial ultrasound, ultrathin bronchoscopy, and electromagnetic navigational bronchoscopy, bronchoscopy has been able to widen its scope in diagnosing pulmonary diseases. In this review, we have described the brief history, role, and complications of bronchoscopy used in diagnosing pulmonary lesions, from simple flexible bronchoscopy to bronchoscopy combined with several up-to-date technologies.

Deadly combination of Vaping-lnduced lung injury and Influenza: case report

BACKGROUND

E-cigarette and vaping use-associated acute lung injury (EVALI) has been recently recognized as a complication in individuals who use vaping devices. Another consideration is that EVALI may have an adverse influence on the outcome of intercurrent respiratory infections. We document this deadly combination in the case of a young man who had EVALI and simultaneous 41 Influenza-A infection leading to severe Acute Respiratory Distress Syndrome (ARDS).

CASE PRESENTATION

A 27-year-old male with a history of tobacco and vaping use was admitted to hospital after two weeks of flu-like symptoms, diarrhea and vomiting. A chest x-ray was consistent with multifocal pneumonia, and microbiological tests were positive for Influenza-A and methicillin-sensitive Staphalacoccus aureus (MSSA). Bronchoscopy provided evidence of acute inhalational injury. After admission, he acutely decompensated with severe hypoxia and hypotension; he required intubation, sedation and vasopressors. He developed sepsis with acute kidney failure, liver failure, biventricular systolic dysfunction and severe rhabdomyolysis. He was placed on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) initially and later changed to Veno-Arterial (VA) ECMO. Nevertheless, the patient continued to deteriorate, and he expired two weeks after admission.

CONCLUSION

This case documents that EVALI can act as a major factor leading a respiratory infection to progress into severe ARDS with a fatal outcome.

Management of severe thermal burns in the acute phase in adults and children

OBJECTIVES

To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children.

DESIGN

A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion.

RESULTS

The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations.

CONCLUSION

Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.

Airway management in inhalation injury: a case series

Inhalation injury is a serious consequence of a fire or an explosion, with potential airway compromise and respiratory complications. We present a case series of five patients with inhalational burns who presented to Singapore General Hospital and discuss our approach to their early management, including early evaluation and planning for the upper and lower airway, coexisting cutaneous burns, and monitoring their ICU (intensive care unit) severity of illness, sepsis and acute respiratory distress syndrome. All five patients suffered various grades of inhalation injury. The patients were initially assessed by nasolaryngoscopy, and three patients were prophylactically intubated before being sent to the emergency operating theatre for definitive airway and burns management with fibreoptic bronchoscopy. All patients were successfully extubated and discharged stable. Various complications can arise as a result of an inhalation injury. Based on our cases and literature review, we propose a standardised workflow for patients with inhalation injury.

Case report of the successful treatment of lung injury caused by occupational exposure to methyl chloroformate and literature review

BACKGROUND

The treatment of acute lung injuries caused by the inhalation of methyl chloroformate remains a difficult clinical problem, with a poor prognosis and a high mortality.

CASE PRESENTATION

After inhalation injuries from methyl chloroformate poisoning, bronchoscopy plays an important role in the diagnosis and treatment of patients. A low tidal air volume and earlier application of steroids are also essential for successful treatment. The grading of acute exposure guideline levels (AEGLs) can direct the selection of a therapeutic regimen for patients with methyl chloroformate poisoning.

CONCLUSIONS

By analyzing the reported acute methyl chloroformate inhalation poisoning cases in China during 1989 to 2017, this study aims to value occupational protection in production activities, accumulate clinical experiences, and provide guidance for the treatment of such cases in the future.

Repeated Bronchoscopy - Treatment of Severe Respiratory Failure in a Fire Victim

A case of respiratory failure in a domestic fire victim presenting with 1-3-degree skin burns on 10% of the total body surface, is reported. Forty-eight hours after admission to hospital, the patient developed severe respiratory failure that did not respond to mechanical ventilation. Severe obstruction of the airway had resulted from secretions and deposits of soot forming bronchial casts. The patient required repeated bronchoscopies to separate and remove the bronchial secretions and soot deposits. An emergency bronchial endoscopic exam was crucial in the patient’s survival and management. The patient was discharged from the hospital after twenty-four days.

The airway in inhalational injury: diagnosis and management

It is estimated that 13.000 to 22.000 individuals suffer from inhalational burns each year in the United States alone. Despite these high numbers, inhalational burns remain a major challenge to otolaryngologists. In this paper, a review of literature is presented in order to provide otolaryngologists with a systematic approach to patients with inhalational burns to optimize treatment, cost, morbidity and, most importantly, mortality. For this purpose, a broad PubMed search was conducted. The available literature was found to highlight the importance of airway management in terms of the timing of intubation, method of intubation, trachea-esophageal (TE) fistula formation and TE rupture. It also emphasizes the importance of carbon monoxide intoxication and prompt correction. Drugs such as heparin sulfate, N-acetylcysteine and albuterol have been proven to help in the treatment of patients with inhalational burns, and more research is currently underway with the purpose of developing chelating drugs that scavenge the toxic substances in the smoke before they can damage the airway.

In view of standardization Part 2: Management of challenges in the initial treatment of burn patients in Burn Centers in Germany, Austria and Switzerland

INTRODUCTION

Initial therapy of severe burns in specialized burn trauma centers is a challenging task faced by the treating multi-professional and interdisciplinary team. A lack of consistent operating procedures and varying structural conditions was recently demonstrated in preliminary data of our group. These results raised the question on how specific treatment measures in acute burn care are met in the absence of standardized guidelines.

MATERIAL AND METHODS

A specific questionnaire containing 57 multiple-choice questions was sent to all 22 major burn centers in Germany, Austria and Switzerland. The survey included standards of airway management and ventilation, fluid management and circulation, body temperature monitoring and management, topical burn wound treatment and a microbiological surveillance. Additionally, the distribution of standardized course systems was covered.

RESULTS

17 out of 22 questionnaires (77%) were returned completed. Regarding volume resuscitation, results showed a similar approach in estimating initial fluid while discrepancies persisted in the use of colloidal fluid and human albumin. Elective tracheostomy and the need for bronchoscopy with suspected inhalation injury were the most controversial issues revealed by the survey. Topical treatment of burned body surface also followed different principles regarding the use of synthetic epidermal skin substitutes or enzymatic wound debridement. Less discrepancy was found in basic diagnostic measures, body temperature management, estimation of the extent of burns and microbiological surveillance.

CONCLUSION

While many burn-related issues are clearly not questionable and managed in a similar way in most participating facilities, we were able to show that the most contentious issues in burn trauma management involve initial volume resuscitation, management of inhalation trauma and topical burn wound treatment. Further research is required to address these topics and evaluate a potential superiority of a regime in order to increase the level of evidence.

Mucosal fluid evaporation is not the method of heat dissipation from fourth-degree laryngopharyngeal burns

This study was designed to explore whether mucosal fluid evaporation represents a method of heat dissipation from thermal air inhalation injury and to assess laryngopharyngeal tissue damage according to heat quantity changes of dry air and vapour. Fifteen adult male beagles were divided into five groups to inhale heated air or vapour for 10 min as follows: control group (ordinary air), group I (91–110 °C heated air), group II (148–175 °C heated air), group III (209–227 °C heated air), and group IV (96 °C saturated vapour). The heat quantity changes of the dry air and vapour were calculated via thermodynamic formulas. The macroscopic and histological features of the laryngopharynxes were examined and assessed by various tissue damage grading systems. Group IV exhibited the most serious laryngopharyngeal damage, including cilia exfoliation, submucosal thrombosis, glandular atrophy, and chondrocyte degeneration, which is indicative of fourth-degree injury. The quality, heat quantity, and proportional reduction of heat quantity of vapour in group IV were all higher than those in the other groups. Furthermore, we found that mucosal fluid evaporation is not the method of heat dissipation from thermal air inhalation injury used by the airways. Laryngopharyngeal tissue damage depends chiefly on the heat quantity of vapour in the air.

Minimally invasive procedures

Minimally invasive procedures, which include laparoscopic surgery, use state-of-the-art technology to reduce the damage to human tissue when performing surgery. Minimally invasive procedures require small "ports" from which the surgeon inserts thin tubes called trocars. Carbon dioxide gas may be used to inflate the area, creating a space between the internal organs and the skin. Then a miniature camera (usually a laparoscope or endoscope) is placed through one of the trocars so the surgical team can view the procedure as a magnified image on video monitors in the operating room. Specialized equipment is inserted through the trocars based on the type of surgery. There are some advanced minimally invasive surgical procedures that can be performed almost exclusively through a single point of entry-meaning only one small incision, like the "uniport" video-assisted thoracoscopic surgery (VATS). Not only do these procedures usually provide equivalent outcomes to traditional "open" surgery (which sometimes require a large incision), but minimally invasive procedures (using small incisions) may offer significant benefits as well: (I) faster recovery; (II) the patient remains for less days hospitalized; (III) less scarring and (IV) less pain. In our current mini review we will present the minimally invasive procedures for thoracic surgery.

Pneumothorax: an up to date "introduction"

The pneumothorax is an abnormal collection of air or gas in the pleural space that separates the lung from the chest wall. Like pleural effusion where a large abnormal concentration of fluid (>100 mL) is liquid buildup in that space, pneumothorax may interfere with normal breathing. A medical term that it is used is the collapsed lung, although that term may also refer to atelectasis. There are two major types of pneumothorax; there is one that occurs without an apparent cause and in the absence of significant lung disease, while the so called; "secondary" pneumothorax occurs in the presence of existing lung pathology. In a minority of cases, the amount of air in the chest increases markedly when a one-way valve is formed by an area of damaged tissue, leading to a third type of pneumothorax, called "tensioned".

Heimlich valve and pneumothorax

The Heimlich valve is a small one-way valve used for chest drainage that empties into a flexible collection device and prevents return of gases or fluids into the pleural space. The Heimlich valve is less than 13 cm (5 inches) long and facilitates patient ambulation. Currently there are several systems in the market. It can be used in many patients instead of a traditional water seal drainage system. The Heimlich chest drainage valve was developed so that the process of draining the pleural cavity could be accomplished in a safe, relatively simple, and efficient manner. This valve system has replaced the cumbersome underwater drainage bottle system. Moreover; the Heimlich valve system connects to chest tubing and allows fluid and air to pass in one direction only. This system functions in any position, and it does not ever need to be clamped, a regulated suction can be attached to it if necessary. The valve drains into a plastic bag that can be held at any level, allowing the patient undergoing chest drainage to be ambulatory simply by carrying the bag. In the current mini review we will present the Heimlich valve system and method of insertion.

Pneumothorax as a complication of central venous catheter insertion

The central venous catheter (CVC) is a catheter placed into a large vein in the neck [internal jugular vein (IJV)], chest (subclavian vein or axillary vein) or groin (femoral vein). There are several situations that require the insertion of a CVC mainly to administer medications or fluids, obtain blood tests (specifically the "central venous oxygen saturation"), and measure central venous pressure. CVC usually remain in place for a longer period of time than other venous access devices. There are situations according to the drug administration or length of stay of the catheter that specific systems are indicated such as; a Hickman line, a peripherally inserted central catheter (PICC) line or a Port-a-Cath may be considered because of their smaller infection risk. Sterile technique is highly important here, as a line may serve as a port of entry for pathogenic organisms, and the line itself may become infected with organisms such as Staphylococcus aureus and coagulase-negative Staphylococci. In the current review we will present the complication of pneumothorax after CVC insertion.

Airway Management in Severe Combat Maxillofacial Trauma

OBJECTIVES

Airway stabilization is critical in combat maxillofacial injury as normal anatomical landmarks can be obscured. The study objective was to characterize the epidemiology of airway management in maxillofacial trauma.

STUDY DESIGN

Retrospective database analysis.

SETTING

Military treatment facilities in Iraq and Afghanistan and stateside tertiary care centers.

SUBJECTS

In total, 1345 military personnel with combat-related maxillofacial injuries sustained March 2004 to August 2010 were identified from the Expeditionary Medical Encounter Database using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes.

METHODS

Descriptive statistics, including basic demographics, injury severity, associated injuries, and airway interventions, were collected. A logistic regression was performed to determine factors associated with the need for tracheostomy.

RESULTS

A total of 239 severe maxillofacial injuries were identified. The most common mechanism of injury was improvised explosive devices (66%), followed by gunshot wounds (8%), mortars (5%), and landmines (4%). Of the subjects, 51.4% required intubation on their initial presentation. Of tracheostomies, 30.4% were performed on initial presentation. Of those who underwent bronchoscopy, 65.2% had airway inhalation injury. There was a significant relationship between the presence of head and neck burn and association with airway inhalation injury (P < .0001). There was also a significant relationship between the severity of facial injury and the need for intubation (P = .002), as well as the presence of maxillofacial fracture and the need for tracheostomy (P = .0001).

CONCLUSIONS

There is a high incidence of airway injury in combat maxillofacial trauma, which may be underestimated. Airway management in this population requires a high degree of suspicion and low threshold for airway stabilization.

Pacemaker insertion

A pacemaker (PM) (or artificial PM, so as not to be confused with the heart's natural PM) is a medical device that uses electrical impulses, delivered by electrodes contracting the heart muscles, to regulate the beating of the heart. The primary purpose of this device is to maintain an adequate heart rate, either because the heart's natural PM is not fast enough, or there is a block in the heart's electrical conduction system. Modern PMs are externally programmable and allow the cardiologist to select the optimum pacing modes for individual patients. Some combine a PM and defibrillator in a single implantable device. PMs can be temporary or permanent. Temporary PMs are used to treat short-term heart problems, such as a slow heartbeat that's caused by a heart attack, heart surgery, or an overdose of medicine. Permanent PMs are used to control long-term heart rhythm problems. A PM can relieve some arrhythmia symptoms, such as fatigue and fainting. A PM also can help a person who has abnormal HRs resume a more active lifestyle. In the current mini review we will focus on the insertion of a PM and the possible pneumothorax that can be caused.

Pneumothorax from diagnosis to treatment, hands on course: Part II

Pneumothorax is a situation where air is inserted in the pleural space that separates the lung from the chest wall. Pneumothorax can be primary or secondary. There is also a third type called; tensioned. Based on the concentration of air and type of pneumothorax the proper treatment has to be selected. There are cases where the concentration is minimal and observation is enough and more severe cases where surgery is required. Currently there are many techniques used for the biopsy of lung lesions. The bronchoscope (forceps, fine needle aspiration), fine needle aspiration under computed tomography scan and endobronchial ultrasound (EBUS) are commonly used. However, all these techniques have in common a possible side effect; pneumothorax. In our current issue we will focus on the different minimally invasive techniques of pneumothorax management. Moreover, a presentation will be made for several systems that are being used for air or fluid aspiration.

Chest drainage systems in use

A chest tube is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air in the case of pneumothorax or fluid such as in the case of pleural effusion, blood, chyle, or pus when empyema occurs from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter. Insertion of chest tubes is widely performed by radiologists, pulmonary physicians and thoracic surgeons. Large catheters or small catheters are used based on each situation that the medical doctor encounters. In the current review we will focus on the chest drain systems that are in use.

Video-assisted thoracic surgery and pneumothorax

Video-assisted thoracoscopic surgery (VATS) is a type of thoracic surgery performed using a small video camera that is introduced into the patient's chest via a scope. It is considered a minimally invasive technique where the surgeon is able to view the instruments that are being used along with the anatomy on which the surgeon is operating. The camera and instruments are inserted through separate holes in the chest wall also known as "ports", depending on the patient and problem there are surgeries with one port "uniport", two or three ports. These small ports have the advantage that fewer infections are observed. This allows for a faster recovery. Traditionally, thoracic surgery performed for diagnosis or treatment of chest conditions has required access to the chest through thoracotomy or sternotomy incisions. Vats minimally invasive technique has replaced in many cases thoracotomy or sternotomy. In our current review we will present this technique in detail.

Semi-Fowler vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis

BACKGROUND AND OBJECTIVE

The aim of this study is to compare usefulness of Semi-Fowler position vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis.

MATERIALS AND METHODS

From January 2009 to January 2010, 263 consecutive patients with palmar and axillar hyperhidrosis underwent thoracoscopic sympathectomy Th2-Th4. Patients were divided into two groups: group A (n=133) underwent thoracoscopic sympathectomy through lateral decubitus using double lumen endotracheal intubation, and group B (n=130) underwent thoracoscopic sympathectomy through Semi-Fowler supine position (semi sitting with arm abducted) using single lumen endotracheal intubation without insufflation of CO2, but with short apnea period. All operations were performed through two 5 mm operating ports, videothoracoscopic camera 0° and endoscopic ultrasound activated harmonic scalpel.

RESULTS

There were 107 males and 156 females with median age 30.31±8.35 years. Two groups were comparable in gender, age, severity of sweating. All operations were successfully performed with no complications or perioperative morbidity. For group A average operation time for both sides was 31.2±3.87 min and for group B average time was 14.19±4.98 min. In group B apnea period per one lung lasts 2.86±1.15 min and during that period observed saturation was 92.65%±5.66% without significant cardiorespiratory disturbances. Pleural drains were taken off on operation table after forced manually lung reexpansion. Patients were discharged from hospital for few hours, after the operation and radiologic confirmation of complete lung reexpansion.

CONCLUSIONS

Based on this data (shorter operating time, lack of incomplete lung collapse, insignificant apnea and better reexpansion of lungs) we concluded that thoracoscopic sympathectomy through Semi-Fowler supine position is highly effective and easy to perform for primary hyperhidrosis.

Open thoracotomy for pneumothorax

A thoracotomy is an incision into the pleural space of the chest. It is performed by surgeons (or emergency physicians under certain circumstances) to gain access to the thoracic organs, most commonly the heart, the lungs, or the esophagus, or for access to the thoracic aorta or the anterior spine. This surgical procedure is a major surgical maneuver it is the first step in many thoracic surgeries including lobectomy or pneumonectomy for lung cancer and as such requires general anesthesia with endotracheal tube insertion and mechanical ventilation, rigid bronchoscope can be also used if necessary. Thoracotomies are thought to be one of the most difficult surgical incisions to deal with post-operatively, because they are extremely painful and the pain can prevent the patient from breathing effectively, leading to atelectasis or pneumonia. In the current review we will present the steps of this procedure.

Barotrauma and pneumothorax

Barotrauma is physical damage to body tissues caused by a difference in pressure between a gas space inside, or in contact with the body, and the surrounding fluid. This situation typically occurs when the organism is exposed to a significant change in ambient pressure, such as when a scuba diver, a free-diver or an airplane passenger ascends or descends, or during uncontrolled decompression of a pressure vessel, but it can also happen by a shock wave. Whales and dolphins are also vulnerable to barotrauma if exposed to rapid and excessive changes in diving pressures. In the current review we will focus on barotraumas from definition to treatment.

Pleura space anatomy

The pleural cavity is the potential space between the two pleurae (visceral and parietal) of the lungs. The pleurae are serous membranes which fold back onto themselves to form a two-layered membranous structure. The thin space between the two pleural layers is known as the pleural cavity and normally contains a small amount of pleural fluid. There are two layers; the outer pleura (parietal pleura) is attached to the chest wall and the inner pleura (visceral pleura) covers the lungs and adjoining structures, via blood vessels, bronchi and nerves. The parietal pleurae are highly sensitive to pain, while the visceral pleura are not, due to its lack of sensory innervation. In the current review we will present the anatomy of the pleural space.

Physiology of the pleural space

The pleural cavity is created between the 4(th) and 7(th) week of embryologic development. These embryonic components of visceral and parietal pleurae develop different anatomic characteristics with regard to vascular, lymphatic, and nervous supply. There are two layers: a superficial mesothelial cell layer facing the pleural space and an underlying connective tissue layer. The pleura might present inflammatory response and maintenance of the pleural fluid is observed. The latter function is especially important in the mechanical coupling of the lung and chest wall. Fluid is filtered into the pleural space according to the net hydrostatic oncotic pressure gradient. It flows downward along a vertical pressure gradient, presumably determined by hydrostatic pressure and resistance to viscous flow. There also may be a net movement of fluid from the costal pleura to the mediastinal and interlobar regions. In these areas, pleural fluid is resorbed primarily through lymphatic stomata on the parietal pleural surface. In the current review we will present the physiology of the pleural space in a step by step manner.

Postoperative pain management

Postoperative pain is a very important issue for several patients. Indifferent of the surgery type or method, pain management is very necessary. The relief from suffering leads to early mobilization, less hospital stay, reduced hospital costs, and increased patient satisfaction. An individual approach should be applied for pain control, rather than a fix dose or drugs. Additionally, medical, psychological, and physical condition, age, level of fear or anxiety, surgical procedure, personal preference, and response to agents given should be taken into account. The major goal in the management of postoperative pain is minimizing the dose of medications to lessen side effects while still providing adequate analgesia. Again a multidisciplinary team approach should be pursued planning and formulating a plan for pain relief, particularly in complicated patients, such as those who have medical comorbidities. These patients might appear increase for analgesia-related complications or side effects.

Approach of the treatment for pneumothorax

Pneumothorax can occur in several situations such as; chronic obstructive pulmonary disease (COPD) where emphysema is observed or due to a biopsy for malignancy suspicion. In any case it is a dangerous situation that requires immediate attention and treatment. Pneumothorax can be divided in primary and secondary. Staging of pneumothorax is also very important. In our current editorial we summarize etiology and treatment of pneumothorax from a panel of pulmonary physicians, oncologists and thoracic surgeons.

Bronchoscopic interventions for severe COPD

Chronic obstructive pulmonary disease (COPD) causes severe handicap among smokers. Most patients have to remain under continuous oxygen therapy at home. Moreover, respiratory infections are very common among these patients and vaccination is obligatory against influenza. Emphysema and bronchiectasis are observed with computed tomography (CT) and in several situations these parenchymal damages are responsible for pneumothorax in one case and pseudomonas aeroginosa infection. Novel mini-invasive techniques are used currently for emphysema treatments which are described extensively throughout our current work.

Pneumothorax in sarcoidosis

While sarcoidosis is a relatively common but often underdiagnosed disease, pneumothorax appears to be a rare clinical event observed mostly at the late stages of the disease course. The precise underlying mechanism of such complication is unclear and probably involves the formation of bullae due to bronchial obstruction and retraction-collapse of distracted lung tissue. Thoracoscopic bullectomy represent the preferred treatment option for recurrent pneumothoraces. The administration of corticosteroids for the treatment of pulmonary sarcoidosis may have a protecting effect for such recurrences, but remains a controversial issue.

Acute respiratory distress syndrome and pneumothorax

Acute respiratory distress syndrome (ARDS) can occur during the treatment of several diseases and in several interventional procedures as a complication. It is a difficult situation to handle and special care should be applied to the patients. Mechanical ventilation is used for these patients and several parameters are changed constantly until compliance is achieved. However, a complication that is observed during the application of positive airway pressure is pneumothorax. In our current work we will present definition and causes of pneumothorax in the setting of intensive care unit (ICU). We will identify differences and similarities of this situation and present treatment options.

Pneumothorax in cystic fibrosis

Pneumothorax is recognized as a common and life-threatening complication in cystic fibrosis (CF) patients, especially in those who are infected with P. aeruginosa, B. cepacia or Aspergillus, need enteral feeding, are diagnosed as suffering from allergic bronchopulmonary aspergillosis (ABPA), developed massive hemoptysis, and their respiratory function is seriously compromised. Structural impairment and altered airflow dynamics in the lungs of CF patients are considered as the main predisposing factors, but also inhaled medications and non-invasive positive pressure ventilation (NIPPV) could increase the risk of pneumothorax. Clinical presentation could range from dramatic to very mild. Management of spontaneous pneumothorax occurring to patients with CF is essentially similar to that for non-CF patients. Therapeutic options include intercostal tube drainage, video-assisted thoracoscopic surgery (VATS), and medical or surgical pleurodesis. Pneumothorax increases both short- and long-term morbidity and mortality in CF patients and causes significant deterioration of their quality of life.

Tube thoracostomy; chest tube implantation and follow up

Pneumothorax is an urgent medical situation that requires urgent treatment. We can divide this entity based on the etiology to primary and secondary. Chest tube implantation can be performed either in the upper chest wall or lower. Both thoracic surgeons and pulmonary physicians can place a chest tube with minimal invasive techniques. In our current work, we will demonstrate chest tube implantation to locations, methodology and tools.

Pneumothorax after transbronchial needle biopsy

Currently there several diagnostic techniques that re used by radiologists and pulmonary physicians for lung cancer diagnostics. In several cases pneumothorax (PNTX) is induced and immediate action is needed. Both radiologists and pulmonary physicians can insert a chest tube for symptom relief. However; only pulmonary physicians and thoracic surgeons can provide a permanent solution for the patient. The final solution would be for a patient to undergo surgery for a final solution. In our current work we will provide all those diagnostic cases where PNTX is induced and treatment from the point of view of expert radiologists and pulmonary physicians.

Transbronchial lung biopsy and pneumothorax

Mini-interventional procedures are used in the everyday clinical practice by pulmonary physicians and radiologists. Fine needle aspiration and biopsy forceps are the tools mostly used. During these procedures pneumothorax can occur and immediate treatment is necessary. In our current work, we will focus on minimal invasive techniques for biopsy and pneumothorax treatment.

Catamenial pneumothorax

Catamenial pneumothorax (CP) is the most common form of thoracic endometriosis syndrome, which also includes catamenial hemothorax, catamenial hemoptysis, catamenial hemopneumothorax and endometriosis lung nodules, as well as some exceptional presentations. Usually onset of lung collapse is less than 72 hours after menstruation. Most commonly occurs in women aged 30-40 years, but has been diagnosed in young girls as early as 10 years of age and post menopausal women (exclusively in women of menstrual age) most with a history of pelvic endometriosis. Diagnosis can be hinted by high recurrence rates of lung collapse in a woman of reproductive age with endometriosis. Moreover; CA-125 is elevated. Video-assisted thoracoscopy or medical thoracoscopy is used for confirmation. In our current work we will present all aspects of CP from diagnosis to treatment.

Penetrating trauma

Pneumothorax occurs when air enters the pleural space. Currently there is increasing incidence of road traffic accidents, increasing awareness of healthcare leading to more advanced diagnostic procedures, and increasing number of admissions in intensive care units are responsible for traumatic (non iatrogenic and iatrogenic) pneumothorax. Pneumothorax has a clinical spectrum from asymptomatic patient to life-threatening situations. Diagnosis is usually made by clinical examination and imaging techniques. In our current work we focus on the treatment of penetrating trauma.

Pneumothorax: observation

Pneumothorax based on the cause, it can be divided into two large categories; primary and secondary. The staging of pneumothorax plays a crucial role for treatment. Currently both thoracic surgeons and pulmonary physicians can handle efficiently treatment. Pulmonary physicians with the minimally medical thoracoscopy while thoracic surgeons with a more extensive intervention. Experience defines the outcome in most situations and not the method. In our current work we will present data regarding the observation of pneumothorax from a panel of experts.

Pneumothorax: from definition to diagnosis and treatment

Pneumothorax is an urgent situation that has to be treated immediately upon diagnosis. Pneumothorax is divided to primary and secondary. A primary pneumothorax is considered the one that occurs without an apparent cause and in the absence of significant lung disease. On the other hand secondary pneumothorax occurs in the presence of existing lung pathology. There is the case where an amount of air in the chest increases markedly and a one-way valve is formed leading to a tension pneumothorax. Unless reversed by effective treatment, this situation can progress and cause death. Pneumothorax can be caused by physical trauma to the chest or as a complication of medical or surgical intervention (biopsy). Symptoms typically include chest pain and shortness of breath. Diagnosis of a pneumothorax requires a chest X-ray or computed tomography (CT) scan. Small spontaneous pneumothoraces typically resolve without treatment and require only monitoring. In our current special issue we will present the definition, diagnosis and treatment of pneumothorax from different experts in the field, different countries and present different methods of treatment.