Use of pleural catheter for the management of simple pneumothorax

Comparison of the results of two chest tube managements during an enhanced recovery program after video-assisted thoracoscopic lobectomy: A randomized trial

BACKGROUND

This study compared the results of the application of two different chest tube management systems; a drainage ball with low negative pressure and the more commonly used chest tube with water-sealed bottle, after video-assisted thoracoscopic (VATS) lobectomy.

METHODS

A total of 60 patients undergoing lobectomy were enrolled into this prospective open label randomized clinical trial and equally divided into two groups. The data collected in the trial included age, gender, forced expiratory volume in 1 second (FEV1), blood loss, operation time, drainage volume, drainage time, length of stay, postoperative pain score according to the Visual Analogue Scale (VAS) within 24 hours after surgery and chest tube removal. This study was registered at ClinicalTrials.gov (NCT03598296).

RESULTS

The characteristics of the patients were similar in both groups. Group ball patients had a lower pain score (after operation: 3.47 ± 1.80 vs. 6.20 ± 1.56, P < 0.001; after removal of chest tube: 1.47 ± 1.28 vs. 3.00 ± 1.29, P < 0.001); less analgesic used (2.83 ± 2.09 times vs. 5.00 ± 3.24 times, P = 0.003); less drainage time (upper tube: 3.89 ± 1.63 days vs. 5.10 ± 2.02 days, P = 0.048; lower tube: upper lobe 4.84 ± 1.61 days vs. 5.90 ± 1.52 days, P = 0.041; lower lobe: 3.82 ± 1.08 days vs. 5.70 ± 2.63 days, P = 0.042) and shorter length of stay (5.40 ± 1.65 days vs. 6.37 ± 1.99 days, P = 0.045). All other related parameters were similar in both groups.

CONCLUSIONS

For patients undergoing lobectomy, using a drainage ball with negative pressure could reduce hospitalization days and postoperative pain compared with the more commonly used chest tube with water-sealed bottle when a strict postoperative curative procedure was performed.

[Different approaches to chest drainage in the management of primary spontaneous pneumothorax]

Drainage of primary spontaneous pneumothorax (PSP) may be managed by different techniques and with different types of drain. It is mainly performed in the pneumology department or in the emergency department. The aim of the study was to evaluate the factors that influence the success of PSP drainage. This retrospective, monocentric study performed in University Hospital of Toulouse, included patients with a first episode of PSP requiring drainage. The primary outcome was the rate of success according to the techniques of drainage. Data on the size of the drain (>14F or<14F), the drainage technique (small bore catheter or chest tube drainage) and the drainage department (pneumology or emergency) were collected. One hundred and twenty-four patients had a drainage between 2014 and 2016: the late recurrence free success rate was 59% (n=73). Compared with emergency, drainage in pneumology increased the success rate threefold regardless of the drainage technique (P=0.0001) The success rate was similar whatever the technique used (Seldinger or classic technique) (P=0.31). Success and complications rates were similar whether the drain was large (>14F) or small (<14F) (respectively P=0.99 and P=0.58). In our study, the drainage of PSP in the pneumology department, with a small caliber inserted by the Seldinger technique, was associated with a significantly higher success rate.

Treatment of Pneumothorax as a Complication of Long-Term Central Venous Port Placement in Oncology Patients. An Observational Study

Background and Purpose

In percutaneous placement of central venous catheters an inadvertent, direct lesion of the lung parenchyma can occur. This is a cause of iatrogenic pneumothorax, whose incidence is approximately 1 to 4%, largely dependent on the experience of the operator, the site of venipuncture and probably the technique employed. Initial treatment currently ranges from observation alone to formal tube-thoracostomy. In an attempt to define the best initial treatment, if any, we reviewed our personal series and contributions from the literature. As a result we have produced a flow-chart proposing a rational treatment of this frequent complication.

Patients and Methods

One thousand four hundred twenty-one ports were placed in patients at the Department of Surgery of the European Institute of Oncology in Milan through an infraclavicular standardized percutaneous subclavian approach. They were placed during the 60-month period from January 1, 1996 to December 31, 2000 for long-term chemotherapy treatment of solid tumours. Chest upright X-rays were obtained post-operatively in all cases to check the correct position of the catheter tip and the presence of pneumothorax.

Results

Twenty-two patients out of 1421 (1.54%) experienced a radiologically-proven pneumothorax, ranging from 5 to 70% of the affected pleural space. Sixteen patients out of 22 (72.7%) with minor portions of affected pleural space received simple observation. In these patients the most common finding was an uncomplicated tachycardia (more than 100 beats/min); 8 of them did not complain of any symptoms. Six patients (27.2%) underwent an additional procedure (3 tube-thoracostomies and 3 aspirations of the pleural space), claiming symptoms of chest pain and various degrees of dyspnea. Tube thoracostomy was mainly adopted at the beginning of our experience, and in patients with a severe degree of pleural involvement (55 to 70% of the pleural space). Aspiration, instead, was used more recently and in patients with varying degrees of pleural space involved, ranging from 40 to 60%.

Conclusions

Looking at our own series and literature data, patients with iatrogenic pneumothorax following central venous cannulation who do not have a severe underlying pulmonary disease can be reassured, at the time of diagnosis, that surgery is usually unnecessary and tube thoracostomy is rarely needed. Simple aspiration of the pleural air by means of a central venous catheter inserted percutaneously into the pleural space under local anesthesia should be considered, even if the amount of affected pleural space is more than 50%, before opting for a formal tube-thoracostomy using small-bore tubes.

Thoracoscopic Surgery for Pneumothorax Following Outpatient Drainage Therapy

PURPOSE

We investigated the outcomes of surgery for pneumothorax following outpatient drainage therapy.

METHODS

We reviewed the records of 34 patients who underwent operations following outpatient drainage therapy with the Thoracic Vent at our hospital between December 2012 and September 2016. Indications for outpatient drainage therapy were pneumothorax without circulatory or respiratory failure and pleural effusion. Indications for surgical treatment were persistent air leakage and patient preference for surgery to prevent or reduce the incidence of recurrent pneumothorax.

RESULTS

Intraoperatively, 9 of 34 cases showed loose adhesions around the Thoracic Vent, all of which were dissected bluntly. The preoperative drainage duration ranged from 5 to 13 days in patients with adhesions and from 3 to 19 days in those without adhesions, indicating no significant difference. The duration of preoperative drainage did not affect the incidence of adhesions. The operative duration ranged from 30 to 96 minutes in patients with adhesions and from 31 to 139 minutes in those without adhesions, also indicating no significant difference.

CONCLUSION

Outpatient drainage therapy with the Thoracic Vent was useful for spontaneous pneumothorax patients who underwent surgery, and drainage for less than 3 weeks did not affect intraoperative or postoperative outcomes.

Outpatient drainage for patients with spontaneous pneumothorax over 50 years of age

Introduction:

The British Thoracic Society has reported a lower success rate for aspiration of spontaneous pneumothorax in patients over 50 years of age. Outpatient drainage therapy is used to manage spontaneous pneumothorax at some institutions. We examined the effect of age on outpatient drainage therapy outcomes.

Materials and Methods:

We reviewed the records of 68 patients who underwent outpatient drainage therapy with a thoracic vent between December 2012 and April 2015, which included 11 patients over 50 years of age. Indications for outpatient drainage therapy included pneumothorax with no circulatory or respiratory failure and no pleural effusion.

Results:

Of the 11 patients over 50 years of age, 5 had chronic obstructive pulmonary disease (COPD), one had interstitial pneumonia, one had a history of pulmonary tuberculosis, and one has lung tumors (LTs). Among the 57 younger patients, 2 patients had COPD, and one had LTs. Unexpected hospital admission occurred in 2 patients over 50 years of age and one patient aged 50 years or less (P = 0.0658, Fisher's exact test). Six of the 11 patients over 50 years of age underwent surgery for prolonged air leakage, compared to 8 of the 57 younger patients (P = 0.00695, Fisher's exact test).

Conclusions:

Outpatient drainage therapy is useful for patients with spontaneous pneumothorax over 50 years of age, because outpatient drainage therapy alone was successful in 4 of 11 patients and admission for drainage was avoided in 9 of 11 patients. However, prolonged air leakage occurs more frequently in this age group.

Effectiveness of Ambulatory Tru-Close Thoracic Vent for the Outpatient Management of Pneumothorax: A Prospective Pilot Study

Objective

This study aimed to assess the technical feasibility, procedural safety, and long-term therapeutic efficacy of a small-sized ambulatory thoracic vent (TV) device for the treatment of pneumothorax.

Materials and Methods

From November 2012 to July 2013, 18 consecutive patients (3 females, 15 males) aged 16–64 years (mean: 34.7 ± 14.9 years, median: 29 years) were enrolled prospectively. Of these, 15 patients had spontaneous pneumothorax and 3 had iatrogenic pneumothorax. A Tru-Close TV with a small-bore (11- or 13-Fr) catheter was inserted under bi-plane fluoroscopic assistance.

Results

Technical success was achieved in all patients. Complete lung re-expansion was achieved at 24 hours in 88.9% of patients (16/18 patients). All patients tolerated the procedure and no major complications occurred. The patients' mean numeric pain intensity score was 2.4 (range: 0–5) in daily life activity during the TV treatment. All patients with spontaneous pneumothorax underwent outpatient follow-up. The mean time to TV removal was 4.7 (3–13) days. Early surgical conversion rate of 16.7% (3/18 patients) occurred in 2 patients with incomplete lung expansion and 1 patient with immediate pneumothorax recurrence post-TV removal; and late surgical conversion occurred in 2 of 18 patients (11.1%). The recurrence-free long-term success rate was 72.2% (13/18 patients) during a 3-year follow-up period from November 2012 to June 2016.

Conclusion

TV application was a simple, safe, and technically feasible procedure in an outpatient clinic, with an acceptable long-term recurrence-free rate. Thus, TV could be useful for the immediate treatment of pneumothorax.

Outpatient Treatment of Pneumothorax with a Thoracic Vent: Economic Benefit

BACKGROUND

Since rising medical costs currently represent a growing problem worldwide, finding cost-effective treatment options is important. In our hospital, outpatient treatment of pneumothorax using a thoracic vent began in December 2012.

OBJECTIVES

We aimed to test our hypothesis that outpatient treatment of pneumothorax with a thoracic vent can reduce medical expenses.

METHODS

Patients were classified into four groups based on treatment: thoracic vent with or without surgery or conventional intercostal chest tube drainage with or without surgery. We compared mean medical expenses, duration of hospitalization and number of physician visits among these four groups.

RESULTS

During a 2-year period, 65 patients were treated with a thoracic vent (36 patients) or conventional intercostal chest tube drainage (29 patients). Patients treated with a thoracic vent who underwent surgery had a shorter mean duration of hospitalization (5.0 ± 1.3 vs. 10.3 ± 3.4 days; p < 0.0001) and lower overall cost, at JPY 971,830.00 ± 81,291.80 (USD 10,400.40 ± 1,464.90) versus JPY 1,179,791.10 ± 198,383.10 (USD 13,888.90 ± 1,965.30; p < 0.0001) compared with conventional intercostal chest tube drainage. Nonsurgical patients treated with a thoracic vent had lower overall costs, at JPY 79,960.00 ± 25,643.60 (USD 890.10 ± 352.30) versus JPY 268,588.80 ± 94,636.50 (USD 2,932.80 ± 903.50; p < 0.0001) compared with conventional intercostal chest tube drainage. No serious complications were observed.

CONCLUSIONS

Outpatient thoracic vent treatment can significantly reduce medical expenses and thereby have a major economic impact.

Outpatient Drainage Therapy with a Thoracic Vent for Traumatic Pneumothorax due to Bull Attack

Outpatient drainage therapy is generally indicated for spontaneous pneumothoraces. A 63-year-old man, who had been attacked by a bull sustaining injuries on the right side of his chest, was referred to the emergency room with dyspnea. His chest X-ray showed a small pneumothorax. The next day, a chest X-ray demonstrated that his pneumothorax had worsened, although no hemothorax was identified. Outpatient drainage therapy with a thoracic vent was initiated. The air leak stopped on the third day and the thoracic vent was removed on the sixth day. Thoracic vents can be a useful modality for treating traumatic pneumothorax without hemothorax.

Randomized clinical trial of pigtail catheter versus chest tube in injured patients with uncomplicated traumatic pneumothorax

BACKGROUND

Small pigtail catheters appear to work as well as the traditional large-bore chest tubes in patients with traumatic pneumothorax, but it is not known whether the smaller pigtail catheters are associated with less tube-site pain. This study was conducted to compare tube-site pain following pigtail catheter or chest tube insertion in patients with uncomplicated traumatic pneumothorax.

METHODS

This prospective randomized trial compared 14-Fr pigtail catheters and 28-Fr chest tubes in patients with traumatic pneumothorax presenting to a level I trauma centre from July 2010 to February 2012. Patients who required emergency tube placement, those who refused and those who could not respond to pain assessment were excluded. Primary outcomes were tube-site pain, as assessed by a numerical rating scale, and total pain medication use. Secondary outcomes included the success rate of pneumothorax resolution and insertion-related complications.

RESULTS

Forty patients were enrolled. Baseline characteristics of 20 patients in the pigtail catheter group were similar to those of 20 patients in the chest tube group. No patient had a flail chest or haemothorax. Pain scores related to chest wall trauma were similar in the two groups. Patients with a pigtail catheter had significantly lower mean(s.d.) tube-site pain scores than those with a chest tube, at baseline after tube insertion (3.2(0.6) versus 7.7(0.6); P < 0.001), on day 1 (1.9(0.5) versus 6.2(0.7); P < 0.001) and day 2 (2.1(1.1) versus 5.5(1.0); P = 0.040). The decreased use of pain medication associated with pigtail catheter was not significantly different. The duration of tube insertion, success rate and insertion-related complications were all similar in the two groups.

CONCLUSION

For patients with a simple, uncomplicated traumatic pneumothorax, use of a 14-Fr pigtail catheter is associated with reduced pain at the site of insertion, with no other clinically important differences noted compared with chest tubes.

REGISTRATION NUMBER

NCT01537289 (http://clinicaltrials.gov).

Ambulatory treatment in the management of pneumothorax: a systematic review of the literature

INTRODUCTION

Spontaneous pneumothorax (SP) is broken down into primary (PSP: no known underlying lung disease), secondary (SSP: known lung disease) and from trauma or iatrogenic pneumothorax (IP). Current treatments include a conservative approach, needle aspiration, chest drain, suction and surgery. A Heimlich valve (HV) is a lightweight one-way valve designed for the ambulatory treatment of pneumothorax (with an intercostal catheter).

METHODS

We performed a systematic review across nine electronic databases for studies reporting the use of HV for adults with pneumothorax. Randomised controlled trials (RCT), case control studies and case series were included, unrestricted by year of publication. Measures of interest included the use only of a HV to manage SP or IP, (ie, avoidance of further procedures), successful treatment as outpatient (OP) and complications.

RESULTS

Eighteen studies were included reporting on the use of HV in 1235 patients, 992 cases of SP (of which 413 were reported as PSP) and 243 IP. The overall quality of the reports was moderate to poor with high risk of bias. Success with HV alone was 1060/1235 (85.8%) and treatment as OP successful in 761/977 (77.9%). Serious complications are rare. Long-term outcomes are comparable with current treatments.

CONCLUSIONS

High-quality data to support the use of HV for ambulatory treatment of pneumothorax is sparse. The use of HV in such circumstances may have benefits for patient comfort, mobility and avoidance of hospital admission, with comparable outcomes to current practice. There is urgent need for a carefully designed RCT to answer his question.

Two-year experience of using pigtail catheters to treat traumatic pneumothorax: a changing trend

BACKGROUND

The traditional treatment of patients with traumatic hemopneumothorax has been an insertion of a chest tube (CT). But CT, because of its large caliber and significant trauma during an insertion, can cause pain, prevent full lung expansion, and worsen pulmonary outcome. Pigtail catheters (PCs) are smaller and less invasive; they have worked well in patients with nontraumatic pneumothorax (PTX). The purpose of this study was to review our early experience of PC use in trauma patients.

METHODS

We retrospectively reviewed the charts of trauma patients who required CT or PC placement over a 2-year period (January 2008 through December 2009) at a Level I trauma center. The PCs were 14-French (14-F) Cook catheters placed by the trauma team, using a Seldinger technique. We compared outcome for the subgroups that had CT or PC placed for a PTX. For our statistical analysis, we used the unpaired Student t-test, χ(2) test, and Wilcoxon rank-sum test; we considered a p value < 0.05 as significant.

RESULTS

Of 9,624 trauma patients evaluated, 94 were treated with PC and 386 with CT. Of the PC patients, 89% was inserted for PTX. When comparing patients with PC and CT inserted for PTX, demographics, tube days, need for mechanical ventilation, and insertion-related complications were similar. The tube failure rate, defined by a requirement for an additional tube or by recurrence that needed intervention, was higher in PC (11%) than in CT (4%) (p = 0.06), but the difference was not statistically significant. We observed a trend of increased PC use over time.

CONCLUSION

PC is safe and can be performed at the bedside. It has a comparable efficacy to CT in patients with PTX. A prospective study is needed to determine the precise role of PC placement, including its indication, the associated tube-site pain, and any significant clinical advantages.

Outpatient management of primary spontaneous pneumothorax in the emergency department of a community hospital using a small-bore catheter and a Heimlich valve

OBJECTIVES

The objective was to assess the effectiveness of a small-bore catheter (8F) connected to a one-way Heimlich valve in the emergency department (ED)-based outpatient management of primary spontaneous pneumothorax (PSP).

METHODS

The authors conducted a structured chart audit in a retrospective case series of patients with PSP who were treated with a small-bore (8F) catheter and a Heimlich valve who were seen in the ED of a community hospital between April 2000 and March 2005. To be eligible, patients had to be available for a telephone interview. Main outcomes were success of treatment (sustained, complete lung reexpansion), admission, and surgical intervention rates. Secondary outcomes included number of chest x-rays (CXRs), number of visits to the ED, treatment duration, complications, and recurrence rates.

RESULTS

The authors identified 62 discrete episodes of PSP in 50 patients, with a mean (+/-standard deviation [SD]) age of 25.5 +/- 10.5 years (range = 14-53 years). In 50 of 62 episodes (81%, 95% confidence interval [CI] = 70.8% to 90.5%), patients were discharged directly from the ED. Patients were admitted to the hospital at some point for treatment in 27/62 episodes (43.5%, 95% CI = 31.2% to 55.9%). Surgery was performed for acute treatment failure in 17 episodes. Ultimately, 19 patients, who accounted for 21 of 62 episodes (33.9%, 95% CI = 22.1% to 45.6%), had surgery at some point in the study. Mean (+/-SD) time to admission for those patients initially discharged from the ED was 2.9 (+/-2.01) days (95% CI = 1.9 to 3.8 days). There were no serious complications from treatment; the minor complication rate (misplacement or dislodging of the chest tube) was 22.6% (95% CI = 12.2% to 33.0%). No association was found between the size of pneumothorax and treatment failure.

CONCLUSIONS

This study suggests that the initial management of PSP with a small-bore catheter and Heimlich valve can easily be performed by emergency physicians in the community hospital setting and appears safe. A larger study systematically comparing this approach with alternative therapies is needed.

Pre-hospital pleural decompression and chest tube placement after blunt trauma: A systematic review

Pre-hospital insertion of chest tubes or decompression of air within the pleural space is one of the controversial topics in emergency medical care of trauma patients. While a wide variety of opinions exist medical personnel on the scene require guidance in situations when tension pneumothorax or progressive pneumothorax is suspected. To ensure evidence based decisions we performed a systematic review of the current literature with respect to the diagnostic accuracy in the pre-hospital setting to identify patients with (tension) pneumothorax, the efficacy and safety of performing pleural decompression in the field and the choice of method and technique for the procedure. The evidence found is presented and discussed and recommendations are drawn from the authors' perspective.

Simple aspiration versus chest-tube insertion in the management of primary spontaneous pneumothorax: a systematic review

BACKGROUND

The initial treatment of a primary spontaneous pneumothorax (PSP) is controversial. Guidelines of the British Thoracic Society recommend simple aspiration for all PSP requiring intervention. The placement of chest tubes is only advocated for patients who fail simple aspiration. However, the American College of Chest Physicians Delphi Consensus Statement found simple aspiration to be rarely appropriate in the management of PSP.

AIMS

To compare simple aspiration with chest-tube drainage in the initial management of PSP.

METHODS

Meta-analysis of randomized controlled trials (RCTs).

OUTCOME MEASURES

Reductions in duration of hospital stay, recurrence rate and pain or dyspnoea score were classified as benefits, whereas reductions in successful events were classified as risks.

DATA COLLECTION AND ANALYSIS

For dichotomous data, the relative risk (RR) and 95% confidence intervals were calculated. For continuous data, weighted mean differences (WMD) were used.

RESULTS

Three RCTs were identified with a combined total of 194 patients. Simple aspiration was associated with shorter hospitalization (WMD -1.30 days [-2.20 to -0.39]). The results for success rate could not be combined because of differences in outcome definitions. However, a pooled result for "success at 1 week or more" showed no significant difference between either intervention (RR 0.86 [0.67, 1.11]). Results of recurrence at 1 year were also not significantly different (RR 0.73 [0.39-1.38]). Different reporting systems for pain scores meant that data could not be pooled. Only one trial reported dyspnoea scores.

CONCLUSION

RCT evidence in this field is limited, and the total sample size is too small to make any firm conclusion. On the basis of current available evidence, simple aspiration is advantageous in the initial management of PSP because of shorter hospitalization. There is no significant difference in recurrence at 1 year using either modality, and the efficacy data are inconclusive.

Comparison of large- and small-bore intercostal catheters in the management of spontaneous pneumothorax

BACKGROUND

Spontaneous pneumothoraces (SP) are a common cause of presentation to emergency departments and subsequent hospitalization. In recent years there has been an increasing trend towards the use of small-bore pleural catheters (PC) rather than conventional large-bore intercostal catheters (ICC) in their initial management.

AIMS

To compare the effectiveness and complication rate of ICC and PC in the treatment of SP.

METHODS

A retrospective chart audit was conducted of 67 cases of SP admitted to the Royal Prince Alfred Hospital, Sydney, Australia, between 1 July 1997 and 30 June 2000. Demographic data were recorded, including: (i) patient age, (ii) smoking status, (iii) pneumothorax size, (iv) pneumothorax type and (v) aetiology. Outcome data relating to length of hospital stay (LOS) and treatment failure rates and complications of treatment devices were also recorded.

RESULTS

Successful pneumothorax resolution was achieved (P = 0.72) in 20 of the 31 (65%) patients initially treated with a ICC, and in 26 of the 36 (72%) patients treated with a PC. The mean LOS in the ICC and PC group was 7 days and 5 days, respectively (P = 0.11). The complication rates in the PC and ICC group were 25% and 10%, respectively (P = 0.13), and the recurrence rates for each group were 17% and 6% (P = 0.20), respectively. However, the combined rate of complications and pneumothorax recurrence within 2 months was 42% in those initially treated with PC, compared with 16% in those treated with ICC (P = 0.04).

CONCLUSIONS

PC were as effective as ICC in treating SP in terms of initial pneumothorax resolution and LOS. There were trends towards higher complication and recurrence rates in those treated with PC, but individually these results did not reach statistical significance. However, the combined rate of complications and pneumo-thorax recurrence was significantly higher in those patients treated with the PC than in those treated with ICC.

Spontaneous pneumothorax: pragmatic management and long-term outcome

We prospectively considered 65 patients admitted for a spontaneous pneumothorax (SP) to describe the pragmatic management of SP, the first recurrence-free interval after medical therapeutic procedure and to specify the first recurrence risk factors over a 7-year period in these patients treated medically. The treatment options were observation alone (9%), needle aspiration (6%), small calibre chest tube (Pleurocatheter) drainage (28%) or thoracic tube drainage (49%), and pleurodesis with video-assisted thoracic surgery procedure (8%). Duration of the drainage and length of hospital stay were shorter in the Pleurocatheter group than in the thoracic tube group (P < 0.01). Among the 47 patients (72%) with a first SP and treated medically, nine patients (19%) had a first homolateral recurrence (FHR) during a mean follow-up of 84+/-13 months. Recurrence-free intervals ranged from 1 to 24 months (mean +/- SD: 9.3+/-8.4 months). FHR cases were more frequent in the Pleurocatheter group (P < 0 04). Analysis of potential risk factors showed that the patient's height and a previous homolateral SP episode are independent recurrence risk factors.

Interventional techniques in the thorax

Transthoracic needle biopsy (TNB) has become the diagnostic procedure of choice in evaluation of focal chest lesions. Both advances in cross-sectional image guidance and cytopathologic techniques allow TNB to accurately diagnose malignancy and characterize a spectrum of benign conditions. Image-guided percutaneous drainage of intrathoracic collections has developed as an extension of similar procedures in the abdomen and pelvis. The ability of CT and ultrasound to accurately detect and characterize parenchymal and pleural collections, and advances in interventional techniques and catheter design, have made percutaneous catheter drainage the treatment of choice for a variety of intrathoracic collections. This article provides an updated review of the spectrum of image-guided diagnostic and therapeutic procedures in the thorax.

Bronchopleural fistula resulting from the use of a thoracic vent: a case report and review

Pneumothorax is defined as the presence of gas or air within the pleural space. Standard treatment is usually based on the evacuation of the gas by various methods. The thoracic vent is a relatively new device used in the treatment of pneumothorax. This report focuses on the first major complication, as far as is known, associated with the use of a thoracic vent.

Outpatient chest tube management

BACKGROUND

Patients with indwelling chest tubes inserted for the purpose of evacuating pleural air traditionally are treated in the hospital. The current emphasis on cost-effective medical care and a recent report describing the early discharge of patients who had undergone lung volume reduction operations and had a persistent air leak prompted us to review our overall experience with outpatient tubes in a general thoracic surgical practice.

METHODS

We reviewed the records of patients who had been discharged from the hospital with chest tubes and Heimlich valves in place for venting pleural air over the past 7 years. Ambulatory tube management was used on a total of 240 occasions in three diagnostic groups: pneumothorax (176 cases), prolonged postresection air leak (45 cases), and outpatient thoracoscopic pulmonary wedge excision (19 cases). Failure was defined as hospital admission for complications of tube insertion or function.

RESULTS

There were 10 failures in the entire group (4.2%), 4.5% for pneumothorax, 2% for postresection air leak, and 5.3% for outpatient thoracoscopy. There were no deaths or instances of life-threatening problems. The cost of at least 1,263 inpatient hospital days was saved.

CONCLUSIONS

The presence of a chest tube, with or without an air leak, does not always require hospitalization. Admission can be avoided in most patients with primary spontaneous pneumothorax and in selected patients with pneumothorax of other causes. The postoperative hospital stay can be shortened for many patients who have a prolonged air leak after pulmonary resection. Ambulatory tube management also makes feasible outpatient thoracoscopy for noneffusive processes.