Retreatment after primary spontaneous pneumothoraxes managed with primary tube thoracostomy or surgery

BACKGROUND AND AIMS

There is a paucity of data on later healthcare visits and retreatments after primary treatment of spontaneous pneumothorax. The main purpose of this study was to describe retreatment rates up to 5 years after primary spontaneous pneumothorax treated with either surgery or tube thoracostomy (TT) at index hospitalization in Finland between 2005 and 2018 to estimate the burden of primary spontaneous pneumothorax on the healthcare system.

METHODS

Retrospective registry-based study of patients with primary spontaneous pneumothorax treated with TT or surgery in Finland in 2005-2018. Rehospitalization and retreatment for recurrent pneumothorax and complications attributable to initial treatment were identified.

RESULTS

The total study population was 1594 patients. At 5 years, 53.2% (384/722) of TT treated and 33.8% (295/872) of surgically treated patients had undergone any retreatment. Surgery was associated with a lower risk of recurrence than TT (hazard ratio (HR) 0.50, 95% confidence interval (CI) 0.43-0.56, p < 0.001). Male sex was associated with a lower risk of recurrent treatment (HR 0.75, 95% CI 0.63-0.90, p = 0.001). Higher age decreased the risk of recurrent treatment (HR 0.99, 95% CI 0.99-0.99, p < 0.001). At 5 years, 36.0% (260/722) of the TT treated and 18.8% (164/872) of the surgically treated had undergone reoperation at some point.

CONCLUSIONS

Reintervention rates and repeat hospital visits after TT and surgery were surprisingly high at long-term follow-up. Occurrences of retreatment and reoperation were significantly higher among primary spontaneous pneumothorax patients treated with TT at index hospitalization than among patients treated with surgery.

Optimizing Precision: A Trajectory Tract Reference Approach to Minimize Complications in CT-Guided Transthoracic Core Biopsy

The advent of computed tomography (CT)-guided transthoracic needle biopsy has significantly advanced the diagnosis of lung lesions, offering a minimally invasive approach to obtaining tissue samples. However, the technique is not without risks, including pneumothorax and hemorrhage, and it demands high precision to ensure diagnostic accuracy while minimizing complications. This study introduces the Laser Angle Guide Assembly (LAGA), a novel device designed to enhance the accuracy and safety of CT-guided lung biopsies. We retrospectively analyzed 322 CT-guided lung biopsy cases performed with LAGA at a single center over seven years, aiming to evaluate its effectiveness in improving diagnostic yield and reducing procedural risks. The study achieved a diagnostic success rate of 94.3%, with a significant reduction in the need for multiple needle passes, demonstrating a majority of biopsies successfully completed with a single pass. The incidence of pneumothorax stood at 11.1%, which is markedly lower than the reported averages, and only 0.3% of cases necessitated chest tube placement, underscoring the safety benefits of the LAGA system. These findings underscore the potential of LAGA to revolutionize CT-guided lung biopsies by enhancing procedural precision and safety, making it a valuable addition to the diagnostic arsenal against pulmonary lesions.

A single center study

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Chest Tube Size Selection: Evaluating Provider Practices, Treatment Efficacy, and Complications in Management of Thoracic Trauma

BACKGROUND

The standard for managing traumatic pneumothorax (PTX), hemothorax (HTX), and hemopneumothorax (HPTX) has historically been large-bore (LB) chest tubes (>20-Fr). Previous studies have shown equal efficacy of small-bore (SB) chest tubes (≤19-Fr) in draining PTX and HTX/HPTX. This study aimed to evaluate provider practice patterns, treatment efficacy, and complications related to the selection of chest tube sizes for patients with thoracic trauma.

METHODS

A retrospective chart review was performed on adult patients who underwent tube thoracostomy for traumatic PTX, HTX, or HPTX at a Level 1 Trauma Center from January 2016 to December 2021. Comparison was made between SB and LB thoracostomy tubes. The primary outcome was indication for chest tube placement based on injury pattern. Secondary outcomes included retained hemothorax, insertion-related complications, and duration of chest tube placement. Univariate and multivariate analyses were performed.

RESULTS

Three hundred and forty-one patients were included and 297 (87.1%) received LB tubes. No significant differences were found between the groups concerning tube failure and insertion-related complications. LB tubes were more frequently placed in patients with penetrating MOI, higher average ISS, and higher average thoracic AIS. Patients who received LB chest tubes experienced a higher incidence of retained HTX.

DISCUSSION

In patients with thoracic trauma, both SB and LB chest tubes may be used for treatment. SB tubes are typically placed in nonemergent situations, and there is apparent provider bias for LB tubes. A future randomized clinical trial is needed to provide additional data on the usage of SB tubes in emergent situations.

Beyond diagnosis: a narrative review of the evolving therapeutic role of medical thoracoscopy in the management of pleural diseases

Background and Objective

Medical thoracoscopy (MT) is an endoscopic technique performed by interventional pulmonologists with a favorable safety profile and few contraindications, providing diagnostic and therapeutic intervention in a single sitting. This narrative review was designed to summarize the therapeutic role of MT based on the latest results from the available literature.

Methods

Pertinent literature published in English, relative to human studies, between 2010-2022 was searched in Medline/PubMed and Cochrane databases. Publications regarded as relevant were considered for inclusion in this review; additional references were added based on the authors' knowledge and judgment. The review considered population studies, meta-analyses, case series, and case reports.

Key Content and Findings

MT has mostly been described and is currently used globally in the diagnostic approach to exudative pleural effusion of undetermined origin. Carefully evaluating the literature, it is clear that there is initial evidence to support the use of MT in the therapeutic approach of malignant pleural effusion, pneumothorax, empyema, and less frequently hemothorax and foreign body retrieval.

Conclusions

MT is an effective procedure for treating the clinical entities presented in this document; it must be carried out in selected patients, managed in centers with high procedural expertise. Further evidence is needed to assess the optimal indications and appropriate patients' profiles for therapeutic MT. The endpoints of length of hospital stay, surgical referral, complications and mortality will have to be considered in future studies to validate it as a therapeutic intervention to be applied globally.

Successful Needle Aspiration of a Traumatic Pneumothorax: A Case Report and Literature Review

Traumatic pneumothorax (PTX) occurs in up to 50% of patients with severe polytrauma and chest injuries. Patients with a traumatic PTX with clinical signs of tension physiology and hemodynamic instability are typically treated with an urgent decompressive thoracostomy, tube thoracostomy, or needle decompression. There is recent evidence that non-breathless patients with a hemodynamically stable traumatic PTX can be managed conservatively through observation or a percutaneous pigtail catheter. We present here a 52-year-old woman who presented to the emergency department with a 55 mm traumatic PTX. Following aspiration of 1500 mL of air, a clinical improvement was immediately observed, allowing the patient to be discharged shortly thereafter. In hemodynamically stable patients with a post-traumatic PTX, without specific risk factors or oxygen desaturation, observation or simple needle aspiration can be a reasonable approach. Although the recent medical literature supports conservative management of small traumatic PTXs, guidelines are lacking for hemodynamically stable patients with a significantly large PTX. This case report documents our successful experience with needle aspiration in such a setting of large traumatic PTX. We aimed in this article to review the available literature on needle aspiration and conservative treatment of traumatic pneumothorax. A total of 12 studies were selected out of 190 articles on traumatic PTX where conservative treatment and chest tube decompression were compared. Our case report offers a novel contribution by illustrating the successful resolution of a sizable pneumothorax through needle aspiration, suggesting that even a large PTX in a hemodynamically stable patient, without other risk conditions, can be successfully treated conservatively with simple needle aspiration in order to avoid tube thoracostomy complications.

Caudal fluoroscopic guidance for the insertion of transvenous pacing leads

BACKGROUND

Pneumothorax is a well-recognized complication of cardiac implantable electronic device (CIED) insertion. While AP fluoroscopy alone is the most commonly imaging technique for subclavian or axillary access, caudal fluoroscopy (angle 40°) is routinely used at our institution. The caudal view provides additional separation of the first rib and clavicle and may reduce the risk of pneumothorax. We assessed outcomes at our institution of AP and caudal fluoroscopic guided pacing lead insertion.

METHODS

Retrospective cohort study of consecutive patients undergoing transvenous lead insertion for pacemakers, defibrillators, and cardiac resynchronization therapy devices between 2011 and 2023. Both de novo and lead replacement/upgrade procedures were included. Data were extracted from operative, radiology, and discharge reports. All patients underwent postprocedure chest radiography.

RESULTS

Three thousand two hundred fifty-two patients underwent insertion of pacing leads between February 2011 and March 2023. Mean age was 71.1 years (range 16-102) and 66.7% were male. Most (n = 2536; 78.0%) procedures used caudal guidance to obtain venous access, while 716 (22.0%) procedures used AP guidance alone. Pneumothoraxes occurred in five (0.2%) patients in the caudal group and five (0.7%) patients in the AP group (p = .03). Subclavian contrast venography was performed less frequently in the caudal group (26.2% vs. 42.7%, p < .01).

CONCLUSION

Caudal fluoroscopy for axillary/subclavian access is associated with a lower rate of pneumothorax and contrast venography compared with an AP approach.

Incidental Diagnosis of Left Pneumothorax Using a New Variant of the Lung Point Sign During Cardiac Ultrasound

BACKGROUND

Pneumothorax is a common issue in the intensive care unit and emergency department, often diagnosed using lung ultrasound. The absence of lung sliding and the presence of the lung point sign are characteristic findings for pneumothorax. We describe a case of left pneumothorax diagnosed incidentally while performing a cardiac ultrasound through a new variant of the lung point sign.

CASE REPORT

A 60-year-old patient with a medical history of diabetes, stroke, and right colon cancer underwent urgent surgical treatment for intestinal sub-occlusion. In the intensive care unit, the patient required mechanical ventilation due to shock unresponsive to fluid administration, and hemodynamic monitoring was performed using echocardiography. During systole in an apical four-chamber view, the abrupt vanishing of the heart was observed. When evaluating the tricuspid annular plane systolic excursion (TAPSE) using M-mode, the interposition of the stratosphere sign during mid-systole prevented the visualization of the TAPSE peak. Lung ultrasound revealed the absence of lung sliding and the presence of the lung point sign on the left side of the thorax, confirming the diagnosis of pneumothorax. A chest x-ray study further confirmed the diagnosis, and urgent drainage was performed. The patient showed improvement in hemodynamic and respiratory conditions and was successfully weaned from mechanical ventilation, and eventually discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: By incorporating the lung ultrasound findings, including this new variant of the lung point sign, into their diagnostic approach to pneumothorax, emergency physicians can promptly initiate appropriate intervention, such as chest tube insertion, leading to improved patient outcomes.

A Foreign Body Aspiration Leading to Pneumothorax: A Case of Airway Emergency

Foreign body (FB) aspiration is a matter that should not be taken lightly. The presence of a foreign object might lead to hazardous complications, particularly in the pediatric population. These complications depend on the type and location of the aspirated object as the tracheobronchial tree has a very small diameter, and foreign bodies become stuck in the upper airways of children, causing stridor and sudden difficulty in breathing. Impaction of a foreign body in the right bronchial tree is more frequent due to the relatively straighter alignment of the right mainstem of the trachea, as opposed to the left side. Herein, we present a 10-year-old Malay boy who accidentally aspirated a pencil cap. An urgent computed tomography (CT) of the thorax revealed a suspicious intraluminal FB in the bronchus leading to pneumothorax and pneumomediastinum. He underwent a right bronchoscopy and a successful FB removal.

Valsalva Manoeuvre-Induced Pneumothorax and Pneumomediastinum in a Covid-19 Patient with ARDS: An Unusual Mechanism for this Complication

Background

Until now, only a few cases of Valsalva-induced barotraumas (pneumothorax, pneumomediastinum and subcutaneous emphysema) have been described, and none of them among COVID-19 patients.

Case description

A man in his 50s was admitted for SARS-CoV-2-related acute respiratory distress syndrome (ARDS). Initial evolution was favourable with non-invasive ventilatory support, high-flow oxygen nasal cannula and the best supportive drugs available at the time. During the Valsalva manoeuvre while defecating, the patient reported sudden chest pain and showed a new acute hypoxemic respiratory failure due to a pneumothorax. It led to multiple complications (pulmonary embolism, haemoptysis, and cardiac arrest), and despite the best supportive care, led to the patient's death.

Discussion

The Valsalva manoeuvre can be an overlooked cause of pneumothorax in patients with COVID-19. Predisposition to barotrauma in COVID-19 patients could be explained by several factors, including the extensive use of non-invasive and invasive ventilation during the pandemic, and the histological changes observed in the lungs of those infected with COVID-19.

Conclusion

We report the first description of a Valsalva-induced barotrauma in a COVID-19 infection. We emphasise the importance of treating constipation particularly in severe COVID-19 cases, to prevent complications such as barotrauma.

LEARNING POINTS

Pneumothorax is a common complication of severe COVID-19 infection, but Valsalva manoeuvre-induced pneumothorax in COVID-19 patients has never been reported previously.Particular care should be taken to prevent and treat constipation in hospitalised patients as it may cause a wide range of complications, including barotraumatism.The extensive use of non-invasive and invasive ventilation may play a role in barotrauma, but causal association has not been proven.

Evaluating postoperative recovery in uniportal versus needlescopic video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: a comparable study

Objectives

Primary spontaneous pneumothorax (PSP) is a common disease in young and thin male. Operation has been regarded as definitive treatment for it. However, the operative methods for those patients are under dispute. This study aims to directly compare the outcomes of uniportal VATS vs. needlescopic VATS in the treatment of PSP, focusing on postoperative pain and safety outcomes.

Methods

From July 2013 to December 2017, the patients who underwent video-assisted thoracic surgery for pneumothorax in National Taiwan University Hospital were retrospectively collected. The preoperative condition, surgical results, and postoperative outcomes was analyzed.

Results

There were 60 patients undergoing needlescopic VATS and 91 undergoing uniportal VATS during the study period. There was no significant difference between the patients who underwent needlescopic VATS and those who underwent uniportal VATS in their demographic and clinical characteristics. The post-operative pain score was significantly lower in the uniportal VATS group compared to the needlescopic VATS group at day 1 (2.65 ± 1.59 vs. 1.74 ± 1.35, p = 0.001).

Conclusion

Uniportal VATS offers an effective, safe alternative for PSP treatment, with benefits including reduced post-operative pain. Our findings support the use of uniportal VATS, supplemented by a wound protector, as a viable option for PSP patients.

Point-of-Care Ultrasound (POCUS) in Adult Cardiac Arrest: Clinical Review

Point-of-Care Ultrasound (POCUS) is a rapid and valuable diagnostic tool available in emergency and intensive care units. In the context of cardiac arrest, POCUS application can help assess cardiac activity, identify causes of arrest that could be reversible (such as pericardial effusion or pneumothorax), guide interventions like central line placement or pericardiocentesis, and provide real-time feedback on the effectiveness of resuscitation efforts, among other critical applications. Its use, in addition to cardiovascular life support maneuvers, is advocated by all resuscitation guidelines. The purpose of this narrative review is to summarize the key applications of POCUS in cardiac arrest, highlighting, among others, its prognostic, diagnostic, and forensic potential. We conducted an extensive literature review utilizing PubMed by employing key search terms regarding ultrasound and its use in cardiac arrest. Apart from its numerous advantages, its limitations and challenges such as the potential for interruption of chest compressions during image acquisition and operator proficiency should be considered as well and are discussed herein.

Automated Real-Time Detection of Lung Sliding Using Artificial Intelligence: A Prospective Diagnostic Accuracy Study

BACKGROUND

Rapid evaluation for pneumothorax is a common clinical priority. Although lung ultrasound (LUS) often is used to assess for pneumothorax, its diagnostic accuracy varies based on patient and provider factors. To enhance the performance of LUS for pulmonary pathologic features, artificial intelligence (AI)-assisted imaging has been adopted; however, the diagnostic accuracy of AI-assisted LUS (AI-LUS) deployed in real time to diagnose pneumothorax remains unknown.

RESEARCH QUESTION

In patients with suspected pneumothorax, what is the real-time diagnostic accuracy of AI-LUS to recognize the absence of lung sliding?

STUDY DESIGN AND METHODS

We performed a prospective AI-assisted diagnostic accuracy study of AI-LUS to recognize the absence of lung sliding in a convenience sample of patients with suspected pneumothorax. After calibrating the model parameters and imaging settings for bedside deployment, we prospectively evaluated its diagnostic accuracy for lung sliding compared with a reference standard of expert consensus.

RESULTS

Two hundred forty-one lung sliding evaluations were derived from 62 patients. AI-LUS showed a sensitivity of 0.921 (95% CI, 0.792-0.973), specificity of 0.802 (95% CI, 0.735-0.856), area under the receiver operating characteristic curve of 0.885 (95% CI, 0.828-0.956), and accuracy of 0.824 (95% CI, 0.766-0.870) for the diagnosis of absent lung sliding.

INTERPRETATION

Real-time AI-LUS shows high sensitivity and moderate specificity to identify the absence of lung sliding. Further research to improve model performance and optimize the integration of AI-LUS into existing diagnostic pathways is warranted.

Benzalkonium Chloride Poisoning in Pediatric Patients: Report of Case with a Severe Clinical Course and Literature Review

The use of disinfectants, particularly those containing quaternary ammonium compounds (QUACs), has dramatically escalated globally since the coronavirus disease 2019 pandemic. We report a case that highlights the risks associated with ingesting low-concentration QUAC solutions and emphasize the importance of effective management in resolving severe lesions without sequelae. A 17-month-old boy experienced severe respiratory failure after ingesting a disinfectant containing benzalkonium chloride (BAC). The child was initially treated at a local emergency department and was subsequently transferred to a pediatric poison center. Upon evaluation, the child was found to have grade III-A corrosive esophageal lesions and chemical pneumonitis. Several complications, including massive pneumothorax and candidemia, occurred during the clinical course of the disease. However, with timely medical intervention and appropriate supportive care, the patient completely recovered without any long-term sequelae. The properties of BAC and the comprehensive management approach may have been responsible for the patient's full recovery, despite the potentially life-threatening effects of ingesting disinfectants.

Computed tomography-guided microwave ablation for right middle lobe pulmonary nodules: a retrospective, single-center, case-control study

PURPOSE

This retrospective, single-center, case-control study evaluated the safety and efficacy of Computed tomography (CT)-guided microwave ablation (MWA) for pulmonary nodules located in the right middle lobe (RML), a challenging location associated with a high frequency of complications.

METHODS

Between May 2020 and April 2022, 71 patients with 71 RML pulmonary nodules underwent 71 MWA sessions. To comparison, 142 patients with 142 pulmonary nodules in non-RML were selected using propensity score matching. The technical success, technique efficacy, complications, and associated factors were analyzed. The duration of the procedure and post-ablation hospital stay were also recorded.

RESULTS

Technical success was achieved in 100% of all patients. There were no significant differences in technique efficacy rates between the RML and non-RML groups (97.2% vs. 95.1%, p = 0.721). However, both major (47.9% vs. 19.7%, p < 0.001) and minor (26.8% vs. 11.3%, p = 0.004) pneumothorax were more common in the RML group than non-RML group. MWA for RML pulmonary nodules was identified as an independent risk factor for pneumothorax (p < 0.001). The duration of procedures (51.7 min vs. 35.3 min, p < 0.001) and post-ablation hospital stays (4.7 days vs. 2.8 days, p < 0.001) were longer in the RML group than non-RML group.

CONCLUSIONS

CT-guided MWA for RML pulmonary nodules showed comparable efficacy compared with other lobes, but posed a higher risk of pneumothorax complications, necessitating longer MWA procedure times and extended hospital stays.

Vanishing Lung Syndrome: A Case Report and Systematic Review of the Literature

Vanishing lung syndrome (VLS), also known as idiopathic giant bullous emphysema, is defined by the emergence of sizable bullae causing compression on healthy lung tissue. The elusive etiology of VLS mandates a diagnosis based on radiographic evidence showcasing giant bullae occupying at least one-third of the hemithorax in one or both lungs. This report presents a case of VLS in a 36-year-old female smoker devoid of any prior medical history. Additionally, we conducted a systematic review to discern the demographics, risk factors, and treatment modalities for individuals diagnosed with VLS.

Chest drainage, a basic but essential procedure

Chest drainage is a basic and important procedure in the treatment of pneumothorax. When properly implemented, even the most severely ill patients may be able to be treated without surgical intervention.

Unexpected Lung Collapse Following Chest Tube Insertion for Pneumothorax Drainage in an Intubated Patient Due to Dislocation of the Endotracheal Tube

A 67-year-old male patient was admitted to the intensive care unit following an uncomplicated heart operation. The initial postoperative chest X-ray revealed a total pneumothorax on the left side. Despite drainage of the left pleural space, a subsequent chest X-ray unexpectedly showed opacification of the left hemithorax. Partial withdrawal of the endotracheal tube resulted in complete expansion of the left lung. It is important to always consider the possibility of endotracheal tube dislocation in all intubated patients.

Pneumothorax caused by metastatic gestational trophoblastic neoplasia: a case report

INTRODUCTION

Gestational trophoblastic neoplasia (GTN) is a group of malignant neoplasms that arise from abnormal proliferation of trophoblastic tissue. The metastatic spread rate is depended on the histopathological type, with pulmonary metastases being the most common (80%) in patients with metastases. Pneumothorax as a primary manifestation is extremely rare. We hereby discuss a unique case of spontaneous hemi-pneumothorax due to metastatic GTN in a 30-weeks pregnant woman.

CASE PRESENTATION

A 25-year-old woman - G2 P0 A1 - was admitted to our maternal intensive care department with atypical respiratory symptoms. A chest x-ray revealed a large right sided pneumothorax. The patient underwent an urgent percutaneous chest tube. Since halting of the suction resulted in residual pneumothorax, a video-assisted thoracoscopic surgery (VATS) with wig resection of a bullous lesion was performed followed by chemical pleurodesis. Histopathological examination identified the lesion as a gestational trophoblastic metastasis with some features of choriocarcinoma. After primary section Caesarea adjuvant chemotherapy (MTX) was instigated with rapid decline of serum HCG values. Six months after surgery she was doing well with no biochemical or radiographic evidence of recurrent metastasis.

CONCLUSION

Lung metastases are common in patients with metastatic GTN; however, pneumothorax is an extremely rare complication. We report a case of pneumothorax in a 30-week pregnant woman caused by pulmonary spread of GTN from a previous miscarriage. This case illustrates that in patients with pneumothorax and a history of miscarriage, metastatic GTN should be considered as a possible cause.

Surgical Resection of a Pneumothorax in an Adult Patient With a History of Wilson-Mikity Syndrome Diagnosed in Childhood

Wilson-Mikity syndrome (WMS) is a rare condition characterized by various respiratory and pulmonary abnormalities in neonates and infants. However, the diagnosis is based on the findings of physiological tests, such as respiratory function tests. Reports describing the histopathological features of WMS are limited. The patient was a 22-year-old woman with a history of WMS. She had been on a ventilator for the first three months of life due to pulmonary hypertension after early delivery at 24 weeks of gestation and required oxygen therapy until three years of age. One month before presenting at our clinic, the patient experienced chest pain and respiratory distress, and a left spontaneous pneumothorax was diagnosed based on a chest X-ray examination. The pneumothorax improved after the insertion of a thoracic drain but recurred soon thereafter. A histopathological examination revealed emphysematous changes associated with WMS in the background lungs, consistent with brevity. No postoperative complications were observed. The thoracic drain was removed on the second day, and the patient was discharged on the eighth postoperative day. Postoperatively, the patient was started on inhaled medication and was carefully monitored every three months. The present case suggests that childhood interviews are very important for adult patients who develop pneumothorax and that early surgical treatment may be selected based on a detailed interview. Moreover, postoperative follow-up should be carefully performed in collaboration with respiratory medicine in patients with pneumothorax originating from chronic obstructive pulmonary diseases such as WMS.

The Role of Pocus in Acute Respiratory Failure: A Narrative Review on Airway and Breathing Assessment

Acute respiratory failure (ARF) is a challenging condition that clinicians, especially in emergency settings, have to face frequently. Especially in emergency settings, many underlying diseases can lead to ARF and life-threatening conditions have to be promptly assessed and correctly treated to avoid unfavorable outcomes. In recent years, point-of-care ultrasound (POCUS) gained growing consideration due to its bedside utilization, reliability and reproducibility even in emergency settings especially in unstable patients. Research on POCUS application to assess ARF has been largely reported mainly with observational studies showing heterogeneous results from many different applications. This narrative review describes the wide potentiality of POCUS to face airways and breathing life-threatening conditions such as upper airway management, pulmonary and pleural pathologies and diaphragm impairment. We conducted extensive research of the literature to report from major studies to case reports deemed useful in practical clinical utilization of POCUS in ARF. Due to the huge amount of the literature found, we focused on airways and breathing assessment trying to systematize the evidence according to clinical care of ARF in emergency settings. Further studies, possibly trials, should determine how POCUS is crucial in clinical practice in terms of standard of care improvements, patient safety and cost-benefit analysis.

Lung-Mimetic Hydrofoam Sealant to Treat Pulmonary Air Leak

Pulmonary air leak is the most common complication of lung surgery, contributing to post-operative morbidity in up to 60% of patients; yet, there is no reliable treatment. Available surgical sealants do not match the demanding deformation mechanics of lung tissue; and therefore, fail to seal air leak. To address this therapeutic gap, a sealant with structural and mechanical similarity to subpleural lung is designed, developed, and systematically evaluated. This "lung-mimetic" sealant is a hydrofoam material that has alveolar-like porous ultrastructure, lung-like viscoelastic properties (adhesive, compressive, tensile), and lung extracellular matrix-derived signals (matrikines) to support tissue repair. In biocompatibility testing, the lung-mimetic sealant shows minimal cytotoxicity and immunogenicity in vitro. Human primary monocytes exposed to sealant matrikines in vitro upregulate key genes (MARCO, PDGFB, VEGF) known to correlate with pleural wound healing and tissue repair in vivo. In rat and swine models of pulmonary air leak, this lung-mimetic sealant rapidly seals air leak and restores baseline lung mechanics. Altogether, these data indicate that the lung-mimetic sealant can effectively seal pulmonary air leak and promote a favorable cellular response in vitro.

Safety assessment of poly-ε-caprolactone in the treatment of primary spontaneous pneumothorax

Background/purpose

Biomaterial-based implants are gaining traction as an option for pleurodesis treatment, yet the search for the best biomaterial or the most suitable shape to handle spontaneous pneumothorax continues. This forward-looking research assessed the use of a poly-ε-caprolactone membrane for its safety when applied as a sclerosant in pleurodesis procedures in human patients.

Methods

From July 2017 to February 2018, we conducted a Phase I trial in which 10 patients with primary spontaneous pneumothorax were treated using video-assisted thoracoscopic surgery with a poly-ε-caprolactone membrane. These procedures encompassed bleb resection and mechanical pleurodesis through parietal pleura scrubbing. After resection, a 150 × 150 mm poly-ε-caprolactone membrane was applied to the apex. The primary outcome measures were the adverse events and laboratory outcomes.

Results

After surgery, we observed no cardiopulmonary-related adverse events or indications of systemic inflammation. Furthermore, no episodes of hypothermia or hyperthermia occurred. Chest radiographs showed no evident pneumonitis or effusion associated with tissue reactions. The average follow-up duration was 31.7 ± 17.7 months, during which two patients exhibited recurrence.

Conclusion

This study is the first to show the biocompatibility of poly-ε-caprolactone in humans, suggesting its potential as a treatment option for patients with primary spontaneous pneumothorax. Despite the relatively small number of patients, we maintain confidence in the reliability and safety profile of the PCL membrane, bolstered by its previously established efficacy in applications involving other organs. Phase II and phase III clinical studies are needed to support these observations.

Detection of Pneumothorax in Severe Acute Respiratory Distress Syndrome-Lung Ultrasound Pitfalls

Lung ultrasound is gaining popularity as a quick, easy, and accurate method for the detection of pneumothorax. The typical sonographic features of pneumothorax are the absence of lung sliding, the presence of a lung point, the absence of a lung pulse, and the absence of B-lines. However, we found that in some cases, each of these elements might be misleading.

Deep Learning for Pneumothorax Detection on Chest Radiograph: A Diagnostic Test Accuracy Systematic Review and Meta Analysis

BACKGROUND

Pneumothorax is a common acute presentation in healthcare settings. A chest radiograph (CXR) is often necessary to make the diagnosis, and minimizing the time between presentation and diagnosis is critical to deliver optimal treatment. Deep learning (DL) algorithms have been developed to rapidly identify pathologic findings on various imaging modalities.

PURPOSE

The purpose of this systematic review and meta-analysis was to evaluate the overall performance of studies utilizing DL algorithms to detect pneumothorax on CXR.

METHODS

A study protocol was created and registered a priori (PROSPERO CRD42023391375). The search strategy included studies published up until January 10, 2023. Inclusion criteria were studies that used adult patients, utilized computer-aided detection of pneumothorax on CXR, dataset was evaluated by a qualified physician, and sufficient data was present to create a 2 × 2 contingency table. Risk of bias was assessed using the QUADAS-2 tool. Bivariate random effects meta-analyses and meta-regression modeling were performed.

RESULTS

Twenty-three studies were selected, including 34 011 patients and 34 075 CXRs. The pooled sensitivity and specificity were 87% (95% confidence interval, 81%, 92%) and 95% (95% confidence interval, 92%, 97%), respectively. The study design, use of an institutional/public data set and risk of bias had no significant effect on the sensitivity and specificity of pneumothorax detection.

CONCLUSIONS

The relatively high sensitivity and specificity of pneumothorax detection by deep-learning showcases the vast potential for implementation in clinical settings to both augment the workflow of radiologists and assist in more rapid diagnoses and subsequent patient treatment.

Traumatic Cardiac Arrest-A Narrative Review

A paradigm shift in traumatic cardiac arrest (TCA) perception switched the traditional belief of futility of TCA resuscitation to a more optimistic perspective, at least in selected cases. The goal of TCA resuscitation is to rapidly and aggressively treat the common potentially reversible causes of TCA. Advances in diagnostics and therapy in TCA are ongoing; however, they are not always translating into improved outcomes. Further research is needed to improve outcome in this often young and previously healthy patient population.

Pneumothorax after percutaneous CT-guided lung nodule biopsy: a prospective, multicenter study

Background

Pneumothorax is a common complication induced by computed tomography (CT)-guided percutaneous needle biopsy, with a frequency of 17-40.4%. It remains debatable how to predict and prevent the occurrence of post-biopsy pneumothorax. In a real-world setting, we investigated the characteristics associated with pneumothorax in primary lung nodule biopsy.

Methods

This clinical registry cohort study recorded patients with newly diagnosed pulmonary nodules from 10 medical centers from April 2021 to April 2022, and the data were input into the electronic data capture (EDC) system. The eligibility criteria for participants included being within the age range of 18 to 80 years and expressing a willingness to undergo percutaneous puncture biopsy, among other requirements. Conversely, the exclusion criteria included an inability to cooperate throughout the biopsy process and the emergence of new health issues during the study duration resulting in attendance delays, among other factors. This study collected data from 924 patients, out of which 593 were included after exclusion. The essential characteristics, imaging features of pulmonary nodules, and technical factors associated with percutaneous biopsy were recorded. T-tests or one-way analysis of variance (ANOVA) were performed for continuous variables and Pearson's χ2 test, likelihood ratio, or Fisher's exact test were applied for categorical variables for comparison as appropriate, followed by multivariate logistic regression.

Results

The overall incidence of pneumothorax was 13.0% (77/593), among which timely pneumothorax was 10.3% (61/593), delayed pneumothorax was 2.7% (16/593), and the rate of chest tube placement was 3.4% (20/593). There was no significant difference in the incidence of pneumothorax in a needle size range of 16-19 G (P=0.129), but the incidence of pneumothorax was lower with 17 G needles than with 18 G. An increased morbidity of pneumothorax was correlated with age (P=0.003), emphysema (P=0.006), and operation time (P=0.002). There was no significant increase in the incidence of pneumothorax between 1 or 2 passes through the pleura (P=0.062). However, multiple pleural passes (3 times) increased the chances of pneumothorax significantly (P=0.022). These risk factors have a certain clinical value in predicting the incidence of post-biopsy pneumothorax, and the area under the curve (AUC) was 0.749.

Conclusions

The most common post-biopsy complication, pneumothorax, was managed conservatively in most cases. A maximum of two pleural passes does not increase the incidence of pneumothorax, and the 17 G needle is more suitable for percutaneous biopsy of pulmonary nodules in the real world.

Risk assessment of pneumothorax in colorectal lung metastases treated by percutaneous thermal ablation: a multicenter retrospective cohort study

PURPOSE

To evaluate the risk of pneumothorax in the percutaneous image-guided thermal ablation (IGTA) treatment of colorectal lung metastases (CRLM).

METHODS

Data regarding patients with CRLM treated with IGTA from five medical institutions in China from 2016 to 2023 were reviewed retrospectively. Pneumothorax and non-pneumothorax were compared using the Student's t -test, χ 2 test and Fisher's exact test. Univariate logistic regression analysis was conducted to identify potential risk factors, followed by multivariate logistic regression analysis to evaluate the predictors of pneumothorax. Interactions between variables were examined and used for model construction. Receiver operating characteristic curves and nomograms were generated to assess the performance of the model.

RESULTS

A total of 254 patients with 376 CRLM underwent 299 ablation sessions. The incidence of pneumothorax was 45.5%. The adjusted multivariate logistic regression model, incorporating interaction terms, revealed that tumour number [odds ratio (OR)=8.34 (95% CI: 1.37-50.64)], puncture depth [OR=0.53 (95% CI: 0.31-0.91)], pre-procedure radiotherapy [OR=3.66 (95% CI: 1.17-11.40)], peribronchial tumour [OR=2.32 (95% CI: 1.04-5.15)], and emphysema [OR=56.83 (95% CI: 8.42-383.57)] were significant predictive factors of pneumothorax (all P <0.05). The generated nomogram model demonstrated a significant prediction performance, with an area under the receiver operating characteristic curve of 0.800 (95% CI: 0.751-0.850).

CONCLUSIONS

Pre-procedure radiotherapy, tumour number, peribronchial tumour, and emphysema were identified as risk factors for pneumothorax in the treatment of CRLM using percutaneous IGTA. Puncture depth was found to be a protective factor against pneumothorax.

Neonatal Subcutaneous Emphysema Secondary to Chest Tube Placement Using the Trocar Technique: A Case Report

Subcutaneous emphysema is a type of air leak in which air accumulates within the subcutaneous layer of the skin underneath the dermal layers. The accumulation of air can be seen on imaging in relevant body areas such as the abdomen, chest, face, or neck. During physical examination, crepitus, the sensation or sound of crackling upon palpation, is the most common associated finding. Various causes for subcutaneous emphysema exist, with one such cause being thoracostomy or chest tube placement. The trocar technique, in particular, has been associated with greater complications when compared to other techniques. Here, we present a case of subcutaneous emphysema in a neonate occurring after placement of a chest tube using the trocar technique. At this time, much of the knowledge regarding subcutaneous emphysema related to chest tube placement is in the adult population. Clinicians should be aware of this complication in neonates as the body of knowledge regarding this topic continues to grow.

Pneumothorax Revealing the Rupture of a Primary Pleural Hydatid Cyst

Primary pleural hydatid cysts are exceptionally uncommon, even in areas where this parasitic infection is prevalent. The occurrence of pneumothorax can serve as an indicator of this condition, presenting a challenge in both diagnosis and treatment when compared to more common causes of pneumothorax. Moreover, hydatid serology often yields negative results, further complicating the diagnosis. Our case study involves a 15-year-old male who experienced a pneumothorax, subsequently revealing a primary pleural hydatid cyst. This report focuses on elucidating its genesis mechanism and outlining its indicative clinical, radiological, and biological characteristics.

Can sub-cutaneous drain safely counter debilitating surgical emphysema? A retrospective study in quest for an answer

Literature evidence on sub-cutaneous drain insertion in severe surgical emphysema (SE) is lacking. We retrospectively reviewed the clinical notes of 5 patients who underwent insertion of sub-cutaneous drains to manage SE of various aetiologies between September 2022 to August 2023 in a single district general hospital in the UK. Case history, outcome following sub-cutaneous drain insertion, and side effects due to the procedure were collected. Clinical decompression were noticed within an hour of drain insertion in all patients. Radiological resolution ranged between 2 and 10 days with a median 3 days and mean of 4.8 days. Patients with uni-lateral sub-cutaneous drain required more time for radiological improvement than patients on bi-lateral drains (median 6.5 vs. 2, mean 6.5 vs. 3.6). Maximum duration for resolution was 10 days for patients receiving uni-lateral sub-cutaneous drain versus 7 days in patients having bi-lateral drains. Only one patient had no prior lung disease making it difficult to comment if having healthy lungs affects outcomes. Sub-cutaneous drain insertion is a safe procedure which can accelerate recovery in severe SE.

Conservative and operative management of spontaneous pneumothorax in children and adolescents: Are we abusing of CT?

BACKGROUND

No age-specific pediatric guidelines exist for the management of spontaneous pneumothorax (SP) in children and adolescents. Treatment remains heterogeneous and center dependent. The role of computed tomography (CT) has yet to be defined.

AIMS

Review the management of SP in children and adolescents, with emphasis on conservative management and role of CT.

METHODS

Retrospective analysis of 61 consecutive patients with SP at single tertiary center. Clinical, radiological, surgical data, follow-up, and outcomes were revised.

RESULTS

First-line management was conservative for 32 (53%) patients and operative for 29 (47%). Asymptomatic/paucisymptomatic patients managed conservatively experienced less first-line treatment failure. Furthermore, the patients needing at least a chest drain or surgery during the follow-up were significantly lower in the conservative group. Conservative and operative patients showed no significant differences regarding ipsilateral recurrences or contralateral occurrences. Of the 61 overall CTs performed, 14 (23%) had an impact on management. Forty-three (70%) patients had at least a CT, in 22 (51%) the CT was positive for blebs. For 10 of these patients (45%) the presence of blebs had an impact on management. Patients with and without blebs showed no differences regarding ipsilateral recurrence, contralateral occurrences, or the need for at least a chest drain or surgery during the follow-up.

CONCLUSIONS

First-line conservative management had a significantly shorter hospitalization and better outcome, with a similar incidence of recurrences. The presence of blebs at CT does not predict the risk of recurrence. The CT scan should be reserved for a small number of selected patients who have post-VATS refractory or recurrent pneumothorax.

Extrapleural air secondary to idiopathic pulmonary fibrosis-related pneumomediastinum

Extrapleural air is a rare condition that may concurrently develop with pneumomediastinum and pneumothorax, especially in older patients with fragile connective tissues. Physicians should consider extrapleural air to prevent inadvertent harm. Coronal reconstruction computed tomography images help appreciate extrapleural air and recognize the track of extrapulmonary air.

Inflammatory endobronchial polyps unleashing recurrent pneumothorax: A case report

Inflammatory endobronchial polyps (IEPs) are rare benign lesions that originate from the bronchial mucosa. While pneumothorax is a well-known complication of various pulmonary conditions, its association with IEPs is exceedingly uncommon and poorly understood. This case report presents a unique and explosive encounter of a patient with an inflammatory endobronchial polyp who experienced a pneumothorax, shedding light on the clinical presentation, diagnostic challenges, and management strategies for this rare entity.

Thoracic trauma in children

Isolated thoracic trauma is rare in children. Because of their small body size, the trauma often also affects other spaces, such as the abdomen and head, and these coexistences significantly increase the rate of mortality. However, in isolated thoracic traumas, the children can quickly recover if they can survive the initial period of trauma. Pediatric thoracic trauma cases can have a different clinical course compared to adults due to the unique anatomic and physiologic properties of children's thoracic cages. Their ribs are nonossified and are very elastic, and therefore, as their ribs can sustain significant deformation without breaking, some significant intrathoracic injuries can be overlooked. In this review, the most common thoracic injuries, including pulmonary contusion, hemopneumothorax, pulmonary laceration, rib fractures, flail chest, tracheobronchial injuries, traumatic asphyxia, and other less common mediastinal injuries are discussed in detail in regard of clinical presentation and management.

Emphysematous changes in pneumoperitoneum and tension pneumothorax following robot-assisted bronchoscopy: a case report

Pneumoperitoneum is most commonly caused by perforation of a hollow viscus but can also result as an extension of pneumothorax and/or pneumomediastinum. We present a case of pneumoperitoneum preceded by intraprocedural hemoptysis and tension pneumothorax that developed during transbronchial needle aspiration using robot-assisted flexible bronchoscopy. After stabilization and management of the pneumothorax, diagnostic laparoscopy was performed and revealed no evidence of diaphragmatic or intra-abdominal perforation but showed diffuse emphysematous changes in the gastrohepatic ligament, small and large bowel mesentery, and preperitoneal space. These findings suggest the implication of subserosal and preperitoneal emphysema as the pathophysiological mechanism of pneumoperitoneum and pneumothorax complicating bronchoscopy procedures.

Periorbital Emphysema Due to Traumatic Pneumothorax

Periorbital emphysema is rare and associated with facial trauma. Its main distinguishing feature is crepitation on palpation of the edema. It resolves spontaneously in a few days, but there are cases of orbital compartment syndrome that can lead to loss of vision. Here we present the case of a 55-year-old male who came to the emergency department for bilateral periorbital edema associated with non-steroidal anti-inflammatory drug (NSAID) usage, for pain following a fall from a ladder. He was treated with antihistamines and corticosteroids, for presumed allergic reaction, but without response, and subsequently developed acute onset dyspnea. Chest x-ray revealed a left pneumothorax in the context of chest trauma. Chest CT scan after drain placement shows extensive subcutaneous emphysema. In the differential diagnosis of periorbital edema, in addition to allergic, inflammatory, and systemic causes, the traumatic ones should not be excluded.

Can the generalizability issue of artificial intelligence be overcome? Pneumothorax detection algorithm

The generalizability of artificial intelligence (AI) models is a major issue in the field of AI applications. Therefore, we aimed to overcome the generalizability problem of an AI model developed for a particular center for pneumothorax detection using a small dataset for external validation. Chest radiographs of patients diagnosed with pneumothorax (n = 648) and those without pneumothorax (n = 650) who visited the Ankara University Faculty of Medicine (AUFM; center 1) were obtained. A deep learning-based pneumothorax detection algorithm (PDA-Alpha) was developed using the AUFM dataset. For implementation at the Health Sciences University (HSU; center 2), PDA-Beta was developed through external validation of PDA-Alpha using 50 radiographs with pneumothorax obtained from HSU. Both PDA algorithms were assessed using the HSU test dataset (n = 200) containing 50 pneumothorax and 150 non-pneumothorax radiographs. We compared the results generated by the algorithms with those of physicians to demonstrate the reliability of the results. The areas under the curve for PDA-Alpha and PDA-Beta were 0.993 (95% confidence interval (CI): 0.985-1.000) and 0.986 (95% CI: 0.962-1.000), respectively. Both algorithms successfully detected the presence of pneumothorax on 49/50 radiographs; however, PDA-Alpha had seven false-positive predictions, whereas PDA-Beta had one. The positive predictive value increased from 0.525 to 0.886 after external validation (p = 0.041). The physicians' sensitivity and specificity for detecting pneumothorax were 0.585 and 0.988, respectively. The performance scores of the algorithms were increased with a small dataset; however, further studies are required to determine the optimal amount of external validation data to fully address the generalizability issue.

Combined use of veno-venous extracorporeal membrane oxygenation and asynchronous independent lung ventilation after thoracic surgery for lung abscess

We used independent lung ventilation (ILV) during veno-venous extracorporeal membrane oxygenation (V-V ECMO) after lung abscess surgery in a patient with severe hypoxia and air leak. ILV can be effective in V-V ECMO as unilateral lung air leak.

[Right upper lobe pulmonary sequestration as a rare cause of recurrent spontaneous pneumothorax]

A 19-year-old patient after previous wedge resection of the right upper pulmonary lobe a year ago urgently admitted with recurrent right-sided spontaneous pneumothorax. According to standard management of spontaneous pneumothorax, we performed diagnostic thoracoscopy and drainage of the right pleural cavity with regular X-ray examinations. However, these measures were ineffective. The patient was scheduled for surgery, and we intraoperatively observed an unusual cause of pneumothorax. Thus, we present spontaneous pneumothorax following right upper lobe pulmonary sequestration. The uniqueness of this case is associated with unusual manifestation and non-standard localization of rare lesion. A few cases of pneumothorax in similar patients are described in the world literature. The key limiting factor in diagnosis of such defects (identification of aberrant vessel supplying abnormal lung parenchyma) is the lack of routine CT angiography in patients diagnosed with pneumothorax. That is why CT changes were interpreted as postoperative ones, and the true cause was established only during redo surgery. A thorough inspection of the pleural cavity and alertness regarding unusual appearance of the right upper pulmonary lobe made it possible to suggest a non-standard diagnosis, avoid complications (bleeding from afferent vessel) and perform adequate lung resection.

A real-world evaluation of the diagnostic accuracy of radiologists using positive predictive values verified from deep learning and natural language processing chest algorithms deployed retrospectively

Objectives

This diagnostic study assessed the accuracy of radiologists retrospectively, using the deep learning and natural language processing chest algorithms implemented in Clinical Review version 3.2 for: pneumothorax, rib fractures in digital chest X-ray radiographs (CXR); aortic aneurysm, pulmonary nodules, emphysema, and pulmonary embolism in CT images.

Methods

The study design was double-blind (artificial intelligence [AI] algorithms and humans), retrospective, non-interventional, and at a single NHS Trust. Adult patients (≥18 years old) scheduled for CXR and CT were invited to enroll as participants through an opt-out process. Reports and images were de-identified, processed retrospectively, and AI-flagged discrepant findings were assigned to two lead radiologists, each blinded to patient identifiers and original radiologist. The radiologist's findings for each clinical condition were tallied as a verified discrepancy (true positive) or not (false positive).

Results

The missed findings were: 0.02% rib fractures, 0.51% aortic aneurysm, 0.32% pulmonary nodules, 0.92% emphysema, and 0.28% pulmonary embolism. The positive predictive values (PPVs) were: pneumothorax (0%), rib fractures (5.6%), aortic dilatation (43.2%), pulmonary emphysema (46.0%), pulmonary embolus (11.5%), and pulmonary nodules (9.2%). The PPV for pneumothorax was nil owing to lack of available studies that were analysed for outpatient activity.

Conclusions

The number of missed findings was far less than generally predicted. The chest algorithms deployed retrospectively were a useful quality tool and AI augmented the radiologists' workflow.

Advances in knowledge

The diagnostic accuracy of our radiologists generated missed findings of 0.02% for rib fractures CXR, 0.51% for aortic dilatation, 0.32% for pulmonary nodule, 0.92% for pulmonary emphysema, and 0.28% for pulmonary embolism for CT studies, all retrospectively evaluated with AI used as a quality tool to flag potential missed findings. It is important to account for prevalence of these chest conditions in clinical context and use appropriate clinical thresholds for decision-making, not relying solely on AI.

Telemedicine-guided thoracentesis of tension pneumothorax in a term newborn

We describe a case of a term female infant born in a rural community hospital and who developed a left-sided spontaneous tension pneumothorax shortly after birth. We used telemedicine to guide the family physician and healthcare team at the referring hospital to perform a life-saving thoracentesis using an intravenous cannula. The cannula was kept in place to drain the persistent pneumothorax during transportation to the pediatric intensive care unit at the tertiary hospital.

Differences in Possible Risk Factors, Treatment Strategies, and Outcomes of Neonatal Pneumothorax in Preterm and Term Infants

OBJECTIVE

The study aimed to compare the risk factors, treatment strategies, and early outcomes of symptomatic neonatal pneumothorax (NP) between preterm and term newborns.

MATERIALS AND METHODS

This retrospective cross-sectional study was conducted in a neonatal intensive care unit between 2015 and 2022, consisting of hospitalized neonates with symptomatic NP. The cases were divided into three groups according to their gestational ages: <340/7 (group 1), 340/7-366/7 (group 2), and ≥370/7 weeks (group 3). Risk factors, treatment strategies, and mortality rates of the study groups were compared using Kruskal-Wallis analysis.

RESULTS

Fifty-nine infants with a diagnosis of symptomatic NP were included in the study. The number of participants was as follows: 25 (42.3%) in group 1, 18 (30.5%) in group 2, and 16 (27.1%) in group 3. The need of delivery room (DR) resuscitation was significantly higher in group 1 (40%, P = .003). The surfactant administration rate was significantly higher in group 1 when compared to group 2 and group 3 (68% vs. 22% and 19%, respectively), P < .001. Similarly, the invasive mechanical ventilation percentage was significantly higher in group 1 than group 2 and group 3, P = .014. However, compared to group 3 (63%), the percentage of chest drain insertion (CDI) need was significantly higher in group 1 (96%) and group 2 (89%) (P = .014).

CONCLUSION

Exposure to DR resuscitation and the need for surfactant are the most common risk factors for NP in preterm infants. Although oxygen and/or needle aspiration treatments are less invasive in symptomatic NP, the improvement rate without CDI is very low in preterm infants born before 34 weeks of gestational age. Cite this article as: Tandırcıoğlu U, Koral Ü, Güzoğlu N, Alan S, Aliefendioğlu D. Differences in possible risk factors, treatment strategies, and outcomes of neonatal pneumothorax in preterm and term infants. Turk Arch Pediatr. 2024;59(1):87-92.

Aggressive approach for spontaneous pneumothorax treatment in children with Marfan syndrome?

Background and objectives

Marfan syndrome (MS) is a systemic disease of connective tissues consisting of a variable combination of anomalies. These patients have an increased risk of spontaneous pneumothorax (SP). However, there is a scarcity of pediatric literature on management, and no specific guidelines exist. Our aim was to analyze the management of spontaneous pneumothorax in children and adolescents with Marfan syndrome, comparing syndromic and non-syndromic patients.

Methods

Retrospective analysis of pediatric patients (18 years) with SP diagnosed at our tertiary pediatric hospital (January 10-June 22), with special emphasis on diagnosis, treatment, and follow-up (FU).

Results

Sixty-six patients with SP were identified, with nine (13%) having MS. In terms of baseline, there were no significant differences between the groups (age, sex, asthma, symptoms, and side, first-line treatment and hospitalization length). Overall, Marfan patients had significantly more first-line treatment failures requiring additional surgery, as well as more contralateral occurrences and the need for surgery/chest drain during the follow-up. Instead, conservative management resulted in significantly more ipsilateral recurrences and the need for surgery/chest drain in Marfan patients than controls during the follow-up.

Conclusions

Treatment failure, contralateral occurrence, ipsilateral recurrence, and the need for surgery/chest drain during follow-up make management of patients with Marfan syndrome and spontaneous pneumothorax more difficult. In patients with a diagnosed MS a more aggressive first-line management should be considered, bearing in mind the higher risks of this population.

Determinants of Pneumothorax Among Mechanically Ventilated COVID-19 Intensive Care Unit Patients, a Single Centre Study

Introduction

Millions of deaths and co-morbidities have been brought on by the COVID-19 epidemic worldwide. Acute respiratory distress syndrome (ARDS), multiple organ failure, and death can result from the condition in some people. The disease's course can range from a moderate upper respiratory tract infection to severe pneumonia. Numerous reports have been made on the occurrence of pneumothorax in COVID-19 ICU patients, particularly in those who are receiving invasive ventilation. This study assesses factors associated with pneumothorax among mechanically ventilated COVID-19 ICU patients in Addis Ababa, Ethiopia.

Methods

A case-control study design was employed from August 1, 2022, to August 31, 2022, GC, with a sample size of 281, where cases are 94 and controls are 187. A pre-tested structured quantitative tool was used to collect data on ODK and export it to SPSS version 26 for analysis. Descriptive statistics were presented using text and tables. The association between variables was analyzed with binary logistic regression. A statistical significance was declared at a p-value of 0.05 with a 95% confidence interval. Assumptions like model fitness and multicollinearity were checked to be satisfied.

Results

A total of 281 (94 cases and 187 controls) patient charts were carefully reviewed. After adjustment for possible confounders in multivariate analysis, ARDS (AOR = 0.214, 95% CI (0.088, 0.519), P value =0.001) and invasive ventilation (AOR = 0.311, 95% CI (0.121, 0.796), P value =0.015) had a significant association with pneumothorax.

Conclusion

Despite the introduction of preventive breathing methods, pneumothorax is still a frequent and deadly consequence in COVID-19 patients with ARDS. ARDS and invasive mechanical ventilation were found to be significantly associated with the development of pneumothorax. Health facilities should be well equipped with recent medical equipment in intensive care units and with well-trained and organized manpower.

Position-Dependent Symptoms of Pneumothorax During Mechanical Ventilation: A Case Report

A 54-year-old male with severe hypoxia was transferred to our hospital after choking on a mochi. Chest computed tomography revealed negative pressure pulmonary edema without pneumothorax. Endotracheal intubation was performed, and pressure-controlled ventilation was initiated. Following admission to the intensive care unit, his respiratory condition was stable in both the supine and left decubitus positions. However, every time he was placed in the right decubitus position, the tidal volume decreased by half, and SpO₂ dropped rapidly to 80%, which recovered soon after returning to the supine position. Chest radiography was performed the following day, revealing grade II right pneumothorax, and a chest tube placement stabilized his respiratory status in the right decubitus position. Air leakage ceased within a few hours. Extubation was successful on the fifth hospital day, and the chest tube was removed on the eighth hospital day. To our knowledge, there are no previous reports on position-dependent symptoms of pneumothorax during mechanical ventilation. Clinicians should consider the possibility of pneumothorax on that same side when respiratory deterioration is observed only in one lateral decubitus position during mechanical ventilation.

Papilledema Secondary to Barotrauma in a Young Adult With Severe Status Asthmaticus With Ventilatory Failure, Pneumothorax, and a Complex Clinical Course

Intubation and mechanical ventilation are common therapeutic interventions in intensive care unit settings. Barotrauma is a known complication of using positive pressures in a tissue defined by extra alveolar air in locations where it is not generally found in patients receiving mechanical ventilation. Several clinical manifestations of barotrauma include pneumothorax, subcutaneous emphysema, pneumoperitoneum, pneumomediastinum or pneumopericardium, air embolization, and hyperinflated left lower lobe. However, papilledema is an unreported and uncommon complication we observed in one of our patients, making it a unique presentation. We present the case of a young male patient intubated for asthma exacerbation requiring mechanical ventilation with subsequent development of papilledema. Our case report highlights the importance of knowing this rare complication of barotrauma as early commencement of lung-protective strategies will help prevent it.