Aerostasis to limit air leak following extended pleurectomy-decortication

Extended pleurectomy-decortication is a cytoreductive surgical treatment for malignant pleural mesothelioma. Prolonged air leak remains a major postoperative challenge, lengthening hospital stay and increasing morbidity. In this video report, we present a stepwise approach for visceral decortication and introduce the concept of aerostasis by construction of an artificial neopleura. Our results suggest that improved aerostasis results in shortened air leak duration.

Pneumothorax Incidence with Normal Saline Instillation for Sealing the Needle Track After Computed Tomography-Guided Percutaneous Lung Biopsy

PURPOSE

To determine whether instillation of normal saline solution for sealing the needle track reduces incidence of pneumothorax and chest tube placement after computed tomography-guided percutaneous lung biopsy.

MATERIALS AND METHODS

A total of 242 computed tomography-guided percutaneous lung biopsies performed at a single institution were retrospectively reviewed, including 93 biopsies in which the needle track was sealed by instillation of 3-5 ml of normal saline solution during needle withdrawal (water seal group) and 149 biopsies without sealing (control group). Patient and lesion characteristics, procedure-specific variables, pneumothorax and chest tube placement rates were recorded.

RESULTS

Baseline characteristics were comparable in both groups. There was a statistically significant decrease in the pneumothorax rate (19.4% [18/93] vs. 40.9% [61/149]; p < 0.001) and a numerically lower chest tube placement rate without significant reduction (4.3% [4/93] vs. 10.7% [16/149]; p = 0.126) with using normal saline instillation for sealing the needle track versus not using sealant material. Using a multiple logistic regression analysis, using normal saline instillation to seal the needle track, having a senior radiologist as operator of the procedure and putting patients in prone position were significantly associated with a decreased risk of pneumothorax. The presence of emphysema along the needle track was significantly associated with an increased risk of pneumothorax. No complication was observed due to normal saline injection.

CONCLUSION

Normal saline solution instillation for sealing the needle track after computed tomography-guided percutaneous lung biopsy is a simple, low-cost and safe technique resulted in significantly decreased pneumothorax occurrence and a numerically lower chest tube placement rate, and might help to reduce both hospitalization risks and costs for the healthcare system. Level of evidence 3 Non-controlled retrospective cohort study.

Intravenous Opioid Medication with Piritramide Reduces the Risk of Pneumothorax During CT-Guided Percutaneous Core Biopsy of the Lung

PURPOSE

CT-guided percutaneous core biopsy of the lung is usually performed under local anesthesia, but can also be conducted under additional systemic opioid medication. The purpose of this retrospective study was to assess the effect of intravenous piritramide application on the pneumothorax rate and to identify risk factors for post-biopsy pneumothorax.

MATERIALS AND METHODS

One hundred and seventy-one core biopsies of the lung were included in this retrospective single center study. The incidence of pneumothorax and chest tube placement was evaluated. Patient-, procedure- and target-related variables were analyzed by univariate and multivariable logistic regression analysis.

RESULTS

The overall incidence of pneumothorax was 39.2% (67/171). The pneumothorax rate was 31.5% (29/92) in patients who received intravenous piritramide and 48.1% (38/79) in patients who did not receive piritramide. In multivariable logistic regression analysis periinterventional piritramide application proved to be the only independent factor to reduce the risk of pneumothorax (odds ratio 0.46, 95%-confidence interval 0.24, 0.88; p = 0.018). Two or more pleura passages (odds ratio 3.38, 95%-confidence interval: 1.15, 9.87; p = 0.026) and prone position of the patient (odds ratio 2.27, 95%-confidence interval: 1.04, 4.94; p = 0.039) were independent risk factors for a higher pneumothorax rate.

CONCLUSION

Procedural opioid medication with piritramide proved to be a previously undisclosed factor decreasing the risk of pneumothorax associated with CT-guided percutaneous core biopsy of the lung. LEVEL OF EVIDENCE 4: small study cohort.

Autologous blood patch intraparenchymal injection reduces the incidence of pneumothorax and the need for chest tube placement following CT-guided lung biopsy: a systematic review and meta-analysis

PURPOSE

To assess the effectiveness of autologous blood patch intraparenchymal injection during CT-guided lung biopsies with a focus on the incidence of pneumothorax and the subsequent requirement for chest tube placement.

METHODS

A comprehensive search of major databases was conducted to identify studies that utilized autologous blood patches to mitigate the risk of pneumothorax following lung biopsies. Efficacy was next assessed through a meta-analysis using a random-effects model.

RESULTS

Of the 122 carefully analyzed studies, nine, representing a patient population of 4116, were incorporated into the final analysis. Conclusion deduced showed a noteworthy reduction in the overall incidence of pneumothorax (RR = 0.65; 95% CI 0.53-0.80; P = 0.00) and a significantly decline in the occasion for chest tube placement due to pneumothorax (RR = 0.45; 95% CI 0.32-0.64; P = 0.00).

CONCLUSIONS

Utilizing autologous blood patch intraparenchymal injection during the coaxial needle retraction process post-lung biopsy is highly effective in diminishing both the incidence of pneumothorax and consequent chest tube placement requirement.

Surfactant therapy guided by tests for lung maturity in preterm infants at risk of respiratory distress syndrome

BACKGROUND

Administration of various exogenous surfactant preparations has been shown to decrease lung injury and pneumothorax and improve survival in very preterm infants with respiratory distress syndrome (RDS). There is no consensus on the threshold for surfactant administration, to allow timely intervention and avoid over-treatment, also considering the invasiveness of the procedure and its cost. Rapid tests for lung maturity, which include the click test, lamellar body counts and stable microbubble test, might guide the identification of those infants needing surfactant administration.

OBJECTIVES

To assess the effects of surfactant treatment guided by rapid tests for surfactant deficiency in preterm infants at risk for or having RDS. Comparison 1: In preterm infants at risk for RDS, does surfactant treatment guided by rapid tests for surfactant deficiency compared to prophylactic surfactant administration to all high-risk infants minimize the need for surfactant treatment and prevent bronchopulmonary dysplasia and mortality? Comparison 2: In preterm infants who require early respiratory support, does surfactant treatment guided by rapid tests for surfactant deficiency compared to surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria minimize the need for surfactant treatment and prevent bronchopulmonary dysplasia and mortality?

SEARCH METHODS

We searched in October 2022 CENTRAL, PubMed, Embase and three additional trial registries. We also screened the reference lists of included studies and related systematic reviews for studies not identified by the database searches.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs evaluating rapid tests after birth for surfactant deficiency in infants at high risk of RDS or requiring respiratory support. We specified two comparisons: 1)surfactant treatment guided by rapid tests for surfactant deficiency versus prophylactic surfactant administration to all high-risk infants in extremely preterm (less than 28 weeks' gestation) and very preterm (28 to 32 weeks' gestation); 2)surfactant treatment guided by rapid tests for surfactant deficiency versus surfactant therapy provided to preterm infants (less than 37 weeks' gestation) with RDS diagnosed on clinical and radiologic criteria.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD), with their 95% confidence intervals (CIs) for dichotomous data. Our primary outcomes were: neonatal mortality, mortality prior to hospital discharge, bronchopulmonary dysplasia and the composite outcome bronchopulmonary dysplasia or mortality. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included three RCTs enrolling 562 newborn infants in this review. No studies compared surfactant treatment guided by rapid tests for surfactant deficiency versus prophylactic surfactant administration to all high-risk infants. Comparing surfactant therapy guided by rapid tests for surfactant deficiency versus surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria. No studies reported neonatal mortality. Compared with surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria, the evidence is very uncertain about the effect of surfactant treatment guided by rapid tests for surfactant deficiency on mortality prior to hospital discharge: RR 1.25, 95% CI 0.65 to 2.41, RD 0.01, 95% CI -0.03 to 0.05, 562 participants, 3 studies; I² for RR and RD = 75% and 43%, respectively; very low-certainty evidence. Surfactant treatment guided by rapid tests for surfactant deficiency may result in little to no difference in bronchopulmonary dysplasia: RR 0.90, 95% CI 0.61 to 1.32, RD -0.02, 95% CI -0.08 to 0.04, 562 participants, 3 studies; I² for RR and RD = 0%; low-certainty evidence. No studies reported the composite outcome bronchopulmonary dysplasia or mortality. Surfactant treatment guided by rapid tests for surfactant deficiency may result in little to no difference in surfactant utilization (RR 0.97, 95% CI 0.85 to 1.11, RD -0.02, 95% CI -0.10 to 0.06, 562 participants, 3 studies, I² for RR and RD = 63% and 65%, respectively, low-certainty evidence), and any pneumothorax (RR 0.53, 95% CI 0.15 to 1.92, RD -0.01, 95% CI -0.04 to 0.01, 506 participants, 2 studies, I² for RR and RD = 0%, low-certainty evidence) compared with surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria. No studies reported moderate to severe neurodevelopmental impairment. We identified two large ongoing RCTs.

AUTHORS' CONCLUSIONS

No studies compared surfactant treatment guided by rapid tests for surfactant deficiency to prophylactic surfactant administration to all high-risk infants. Low to very low-certainty evidence from three studies is available on surfactant therapy guided by rapid tests for surfactant deficiency versus surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria. No studies reported neonatal mortality, the composite outcome 'bronchopulmonary dysplasia or mortality', or neurodevelopmental outcomes. Compared with surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria, the evidence is very uncertain about the effect of surfactant treatment guided by rapid tests for surfactant deficiency on mortality prior to hospital discharge. Surfactant treatment guided by rapid tests for surfactant deficiency may result in little to no difference in bronchopulmonary dysplasia, surfactant utilization and any pneumothorax. The findings of the two large ongoing trials identified in this review are likely to have an important impact on establishing the effects of surfactant treatment guided by rapid tests for surfactant deficiency in preterm infants.

Postoperative hormonal therapies reduce the recurrence of thoracic endometriosis-related pneumothorax

OBJECTIVES

Thoracic endometriosis-related pneumothorax (TERP) frequently recurs even after surgery. Meanwhile, postoperative hormonal therapies (HTx) are believed to be effective for pelvic endometriosis. Therefore, we evaluated the relationship between postoperative TERP recurrence and postoperative HTx in a retrospective observational study.

METHODS

We retrospectively reviewed the data of patients with TERP who underwent the first video-assisted thoracoscopic surgery between January 2011 and February 2022.

RESULTS

Of the 248 patients eligible for this study, 67 (27.0%) experienced postoperative TERP recurrence. Postoperative HTx were administered to 70 patients (28.2%). Dienogest was the most frequently administered drug, given to 56.7% of patients. Following univariable analysis, postoperative hormonal therapies was closely related to reduce postoperative recurrence (P = 0.003). Likewise, the multivariable analysis revealed postoperative hormonal therapies were significantly associated with the risk reduction of recurrence (hazard ratio 0.28, P < 0.001).

CONCLUSIONS

Postoperative HTx reduced TERP recurrence. We hypothesize that HTx may control residual endometrial tissues to avoid TERP if pleural endometrial tissues are resected as much as possible.

Evaluating and developing sealants for the prevention of pulmonary air leakage: A systematic review of animal models

Sealants may provide a solution for pulmonary air leakage (PAL), but their clinical application is debatable. For sealant comparison, standardized animal models are lacking. This systematic review aims to assess methodology and quality of animal models for PAL and sealant evaluation. All animal models investigating lung sealing devices (e.g., staplers, glues, energy devices) to prevent or treat PAL were retrieved systematically from Embase, Pubmed and Web of science. Methodological study characteristics, risk of bias, reporting quality and publication bias were assessed. A total of 71 studies were included (N  =  75 experiments, N  =  1659 animals). Six different species and 18 strains were described; 92% of experiments used healthy animals, disease models were used in only six studies. Lesions to produce PAL were heterogenous, and only 11 studies used a previously reported technique, encompassing N  =  5 unique lesions. Clinically relevant outcomes were used in the minority of studies (imaging 16%, air leak 10.7%, air leak duration 4%). Reporting quality was poor, but revealed an upward trend per decade. Overall, high risk of bias was present, and only 18.7% used a negative control group. All but one study without control groups claimed positive outcomes (95.8%), in contrast to 84.3% using positive or negative control groups, which also concluded equivocal, adverse or inconclusive outcomes. In conclusion, animal studies evaluating sealants for prevention of PAL are heterogenous and of poor reporting quality. Using negative control groups, disease models and quantifiable outcomes seem important to increase validity and relevance. Further research is needed to reach consensus for model development and standardization.

Early nasal intermittent positive pressure ventilation (NIPPV) versus early nasal continuous positive airway pressure (NCPAP) for preterm infants

BACKGROUND

Nasal continuous positive airway pressure (NCPAP) is a strategy to maintain positive airway pressure throughout the respiratory cycle through the application of a bias flow of respiratory gas to an apparatus attached to the nose. Early treatment with NCPAP is associated with decreased risk of mechanical ventilation exposure and might reduce chronic lung disease. Nasal intermittent positive pressure ventilation (NIPPV) is a form of noninvasive ventilation delivered through the same nasal interface during which patients are exposed to short inflations, along with background end-expiratory pressure.

OBJECTIVES

To examine the risks and benefits of early (within the first six hours after birth) NIPPV versus early NCPAP for preterm infants at risk of or with respiratory distress syndrome (RDS). Primary endpoints are respiratory failure and the need for intubated ventilatory support during the first week of life. Secondary endpoints include the incidence of mortality, chronic lung disease (CLD) (oxygen therapy at 36 weeks' postmenstrual age), pneumothorax, duration of respiratory support, duration of oxygen therapy, and intraventricular hemorrhage (IVH).

SEARCH METHODS

Searches were conducted in January 2023 in CENTRAL, MEDLINE, Embase, Web of Science, and Dissertation Abstracts. The reference lists of related systematic reviews and of studies selected for inclusion were also searched.

SELECTION CRITERIA

We considered all randomized and quasi-randomized controlled trials. Eligible studies compared NIPPV versus NCPAP treatment, starting within six hours after birth in preterm infants (< 37 weeks' gestational age (GA)).

DATA COLLECTION AND ANALYSIS

We collected and analyzed data using the recommendations of the Cochrane Neonatal Review Group.

MAIN RESULTS

We included 17 trials, enrolling 1958 infants in this review. NIPPV likely reduces the rate of respiratory failure (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.54 to 0.78; risk difference (RD) -0.08, 95% CI -0.12 to -0.05; 17 RCTs, 1958 infants; moderate-certainty evidence) and needing endotracheal tube ventilation (RR 0.67, 95% CI 0.56 to 0.81; RD -0.07, 95% CI -0.11 to -0.04; 16 RCTs; 1848 infants; moderate-certainty evidence) amongst infants treated with early NIPPV compared with early NCPAP. The meta-analysis demonstrated that NIPPV may reduce the risk of developing CLD compared to CPAP (RR 0.70, 95% CI 0.52 to 0.92; 12 RCTs, 1284 infants; low-certainty evidence) slightly. NIPPV may result in little to no difference in mortality (RR 0.82, 95% CI 0.62 to 1.10; 17 RCTs; 1958 infants; I2 of 0%; low-certainty evidence), the incidence of pneumothorax (RR 0.92, 95% CI 0.60 to 1.41; 16 RCTs; 1674 infants; I2 of 0%; low-certainty evidence), and rates of severe IVH (RR 0.98, 95% CI 0.53 to 1.79; 8 RCTs; 977 infants; I2 of 0%; low-certainty evidence).

AUTHORS' CONCLUSIONS

When applied within six hours after birth, NIPPV likely reduces the risk of respiratory failure and the need for intubation and endotracheal tube ventilation in very preterm infants (GA 28 weeks and above) with respiratory distress syndrome or at risk for RDS. It may also decrease the rate of CLD slightly. However, most trials enrolled infants with a gestational age of approximately 28 to 32 weeks with an overall mean gestational age of around 30 weeks. As such, the results of this review may not apply to extremely preterm infants that are most at risk of needing mechanical ventilation or developing CLD. Additional studies are needed to confirm these results and to assess the safety of NIPPV compared with NCPAP alone in a larger patient population.

[Predictive model for additional intraoperative placement of chest drainage after thoracoscopic lobectomy]

OBJECTIVE

To create a prognostic model determining the risk of tension pneumothorax and the need for intraoperative installation of additional drainage after thoracoscopic lobectomy.

MATERIAL AND METHODS

A retrospective multiple-center study included patients who underwent thoracoscopic lobectomy for lung cancer between 2016 and 2022. One drainage tube was used after surgery in all cases. We synthesized data to expand patient selection using the Riley method and machine learning algorithm. In total, treatment outcomes in 1458 patients were analyzed. After identifying significant factors, we performed binary logistic regression analysis using backward stepwise inclusion of variables in accordance with the Akaike information criterion. After validating the model using the Bootstrap method (400 iterations) and original data set, we created a nomogram determining scoring characteristics, linear predictors and risk of postoperative tension pneumothorax.

RESULTS

The incidence of tension pneumothorax was 4.53% (n=66). The most significant variables associated with pneumothorax and the need for additional pleural drainage were adhesions, intraoperative lung suturing, unclear interlobar groove, enlarged intrapulmonary lymph nodes and chronic obstructive pulmonary disease (p<0.001). The model's C-index was 0.957, mean absolute calibration error - 0.6%, calibration curve slope - 0.959. A score of 26 indicated a 95% risk of postoperative pneumothorax.

CONCLUSION

We developed a prognostic model for tension pneumothorax after thoracoscopic lobectomy. Nomogram makes it possible to make a decision on intraoperative installation of additional pleural drainage tube and prevent complications associated with postoperative lung collapse.

Preventive tract embolization with gelatin sponge slurry is safe and considerably reduces pneumothorax after CT-guided lung biopsy with use of large 16-18 coaxial needles

OBJECTIVE

To evaluate the clinical impact of the tract embolization technique using gelatin sponge slurry after percutaneous CT-guided lung biopsy.

METHODS

We retrospectively compared coaxial needle CT-guided lung biopsies performed without embolization (100 patients) and with the tract embolization technique using a mixture of iodine and gelatin sponge slurry (105 patients) between June 2012 and July 2020. Uni- and multivariate analyses were performed between groups to determine risk factors of pneumothorax.

RESULTS

Patients with gelatin sponge slurry tract embolization had statistically lower rates of pneumothorax ((17.1% vs 39%, p < 0.001). In univariate analysis, tract embolization (OR = 0.32, CI = 0.17-0.61 p<0.001) and nodule size >2 cm (OR = 0.33 CI = 0.14-0.8 p = 0.013) had a protective effect on pneumothorax. The puncture path lengths > 2-20 mm and >20 mm were risk factors for pneumothorax (OR = 3.35 IC = 1.44-8.21 p = 0.006 and OR = 4.36 CI = 1.98-10.29 p<0.001, respectively). In multivariate regression analysis, tract embolization had a protective effect of pneumothorax (OR = 0.25, CI = 0.12-0.51, p < 0.001). The puncture path lengths > 2-20 mm and >20 mm were risk factors for pneumothorax (p = 0.030 and p = 0.002, respectively).

CONCLUSIONS

The tract embolization technique using iodinated gelatin sponge slurry is safe and considerably reduces pneumothorax after percutaneous CT-guided lung biopsy. Our results suggest that it could be use in clinical routine.

ADVANCES IN KNOWLEDGE

The systemic use of gelatin sponge slurry is safe and reduces considerably the rate of pneumothorax upon needle removal when CT-guided core biopsies are performed using large 16-18G coaxial needles.

Multicentre, prospective, observational study investigating the most appropriate surgical option that can prevent the recurrence of primary spontaneous pneumothorax after surgery: the PATCH study, protocol

INTRODUCTION

Thoracoscopic surgery is performed for refractory or recurrent primary spontaneous pneumothorax (PSP). To reduce postoperative recurrence, additional treatment is occasionally adopted during surgery after bulla resection. However, the most effective method has not been fully elucidated. Furthermore, the preference for additional treatment varies among countries, and its efficacy in preventing recurrence must be evaluated based on settings tailored for the conditions of a specific country. The number of registries collecting detailed data about PSP surgery is limited. Therefore, to address this issue, a prospective multicentre observational study was performed.

METHODS AND ANALYSIS

This multicentre, prospective, observational study will enrol 450 participants aged between 16 and 40 years who initially underwent PSP surgery. Data about demographic characteristics, disease and family history, surgical details, and CT scan findings will be collected. Follow-up must be conducted until 3 years after surgery or in the event of recurrence, whichever came first. Patients without recurrence will undergo annual follow-up until 3 years after surgery. The primary outcome is the rate of recurrence within 2 years after surgery. A multivariate analysis will be performed to compare the efficacy of different surgical options. Then, adverse outcomes correlated with various treatments and the feasibility of treatment methods will be compared.

ETHICS AND DISSEMINATION

This study was approved by the local ethics committee of all participating centres. The findings will be available in 2025, and they can be used as a basis for clinical decision-making regarding appropriate options for the initial PSP surgery.

TRIAL REGISTRATION NUMBER

NCT04758143.

Prediction model of rhomboid major and pleura depth based on anthropometric features to decrease the risk of pneumothorax during dry needling

BACKGROUND

Although most common adverse events associated with dry needling can be considered minor, serious adverse events including induced pneumothorax cannot be excluded, and safety instructions for reducing the risk of pleura puncture are needed.

OBJECTIVE

To investigate if anthropometric features can predict the rhomboid major muscle and pleura depth in a sample of healthy subjects to avoid the risk of pneumothorax during dry needling.

METHODS

A diagnostic study was conducted on 59 healthy subjects (52.5% male) involving a total of 236 measurements (both sides in maximum inspiration and expiration), to calculate the accuracy of a prediction model for both pleura and rhomboid depth, as assessed with ultrasound imaging, based on sex, age, height, weight, body mass index (BMI), breathing and chest circumference. A correlation matrix and a multiple linear regression analyses were used to detect those variables contributing significantly to the variance in both locations.

RESULTS

Men showed greater height, weight, BMI, thorax circumference and skin-to-rhomboid, rhomboid-to-pleura and skin-to-pleura distances (P < .001). Sex, BMI, and thorax circumference explained 51.5% of the variance of the rhomboid (P < .001) and 69.7% of pleura (P < .001) depth limit. In general, inserting a maximum length of 19 mm is recommended to reach the deep limit of rhomboid major decreasing the risk of passing through the pleura.

CONCLUSION

This study identified that gender, BMI and thorax circumference can predict both rhomboid and pleura depth, as assessed with ultrasonography, in healthy subjects. Our findings could assist clinicians in the needle length election in avoiding the risk of induced pneumothorax during dry needling.

Efficacy of Commercial Chest Seal Adherence and Tension Pneumothorax Prevention: A Systematic Review of Quantitative Studies

BACKGROUND

Penetrating thoracic injuries account for an essential subset of battlefield and civilian injuries that result in death. Current recommendations are to use commercially available nonocclusive chest seals. We review current evidence for which chest seal(s) is likely to be the most effective in treating open pneumothoraces.

METHODS

A systematic review was conducted in accordance with the PRIMSA 2009 standard systematic review methodology, except where noted. The databases Pubmed, MEDLINE, CINAHL, Scopus, and gray sources were searched for all English-language, full-manuscript, experimental, quantitative studies of humans and animals concerning seal adherence or their efficacy at preventing tension pneumothoraces published between 1990 and 2020. A numerical analysis was used to provide the consensus recommendation.

RESULTS

Of 683 eligible identified articles [PubMed 528 (77.3%), Scopus 87 (12.7%), CINAHL 67 (9.8%), one (0.1%) unpublished], six (0.9%) articles were included. Synthesis of all studies' results suggests a consensus recommendation for the Hyfin Vent Chest Seal and Russell Chest Seal. These two were the most effective chest seals, as previously investigated in a quantifiable, experimental study.

CONCLUSION

While chest seals are recommended in civilian and military prehospital medicine to improve patient survival, current evidence concerning the individual device's efficacy is limited. Further scientific, quantitative research is needed to clarify which commercially available chest seals are most effective and provide patients with penetrating chest trauma the best possible method for preventing or mitigating tension pneumothoraces.

Follow-Up of Blebs and Bullae in Pilots 40 Years and Older Using CT

BACKGROUND: Preventive treatment for incidentally detected blebs or bullae is required for fast jet pilots, but their aeromedical risk is not clearly proven.METHODS: This is a retrospective study and includes 46 pilots 40 yr and older with incidentally detected emphysema-like changes (ELCs) comprising blebs or bullae in low-dose chest CT (LDCT) during health screening. Two radiologists retrospectively reviewed imaging features. Statistical analysis was done using independent t-tests and bivariate analysis.RESULTS: Among 46 pilots, 39 pilots flew fast jet aircraft and 7 pilots flew nonfast jet aircraft. The mean follow-up period was 1531 d and the LDCT follow-up interval mean period was 424.4 d. There was no evidence of rupture in incidentally detected ELCs during the follow-up period. The mean size of the ELCs was 19.15 mm. There were five cases showing changes in size. There was a statistically significant correlation between the size of ELCs and height. There were no statistically significant differences in the size or number of ELCs relating to smoking status or aircraft type, and there were no statistically significant correlations between the size or number of ELCs and multiple factors, including smoking quantity, flight time, age, BMI, and weight.CONCLUSION: This study demonstrates the aeromedical safety of incidentally detected ELCs in pilots 40 yr and older without underlying lung disease. The results indicate no need for recommending preventive treatment for ELCs in pilots 40 yr and older, even those flying fast jet aircraft, as a requisite to continue their flight duties. KEYWORDS: bleb, bulla, pilot, CT.Bang S, Yang S, Cho SW, Kim DH, Kang H. Follow-up of blebs and bullae in pilots 40 years and older using CT. Aerosp Med Hum Perform. 2019; 90(10):867-871.

Pulmonary pathologic alterations associated with biopsy inserted hydrogel plugs

The prevention of pneumothorax after percutaneous lung biopsy is a major patient safety concern. The insertion of hydrogel plugs into biopsy sites to mitigate this complication is a new intervention. The histology of the plug has not been previously reported, and in this study the histologic reaction is reported in 13 cases. The hydrogel plug forms a spherical basophilic matrix pool with an adjacent foreign body giant cell reaction and patchy eosinophilia. No extension to the pleural surface is present. The potential diagnostic errors related to the presence of the plug are discussed.

Cost-effectiveness of hydrogel plugs in CT-guided lung biopsies

OBJECTIVE

Using a hydrogel plug decreases the number of cases of pneumothorax and reduces the need for pleural drainage tubes in CT-guided lung biopsies. We aimed to analyze the cost-effectiveness of using hydrogel plugs.

MATERIAL AND METHODS

We analyzed 171 lung biopsies divided into three groups: Group 1 (n=22): fine-needle aspiration cytology (FNAC) without hydrogel plugs; Group 2 (n=89): FNAC with hydrogel plugs; and Group 3 (n=60): FNAC plus core-needle biopsy (CNB) with hydrogel plugs. We calculated the total costs (direct and indirect) in the three groups. We analyzed the percentage of correct diagnoses, the average and incremental rations, and the most cost-effective option.

RESULTS

Total costs: Group 1 = 1,261.28 + 52.65 = € 1,313.93; Group 2 = 1,201.36 + 67.25 = € 1,268.61; Group 3 = 1,220.22 + 47.20 = € 1,267.42. Percentage of correct diagnoses: Group 1 = 77.3%, Group 2 = 85.4%, and Group 3 = 95% (p = 0.04). Average cost-effectiveness ratio: Group 1 = 16.99; Group 2 = 14.85; and Group 3 = 13.34.

CONCLUSIONS

Group 3 was the best option, with the lowest average cost-effectiveness ratio; therefore, the most cost-effective approach is to do FNAC and CNB using a dehydrated hydrogel plug at the end of the procedure.

[Totally implantable central venous port: analysis of complications and their prevention]

OBJECTIVE

To analyze postoperative complications of totally implantable central venous port system (TIPCVP) deployment and develop methods of their prevention.

MATERIAL AND METHODS

The study involved 43 patients who underwent TIPCVP implantation through right-sided jugular access and 3 patients with migration of the catheter transferred to the Domodedovo Central City Hospital.

RESULTS

There were four perioperative and one early postoperative complication. None of the complications was the reason for removal of TIPCVP. Pinch-off syndrome occurred in two patients who were operated in other hospitals and a catheter was inserted through the right subclavian vein.

CONCLUSION

Injury of the carotid artery and pneumothorax can be avoided by ultrasound navigation during internal jugular vein puncture. Catheterization of the internal jugular vein is useful to avoid pinch-off syndrome. Migration of the catheter is successfully cured by endovascular methods.

CPR-related thoracic injuries: comparison of CPR guidelines between 2010 and 2015

Background/aim: This study aimed to evaluate traumatic thorax complications in post-CPR patients and to investigate whether or not there has been a decrease in these complications since the adoption of current chest compression recommendations. Materials and methods: Post-CPR patients with return of spontaneous circulation (ROSC) were admitted between January 2014 and January 2016 were analyzed retrospectively. Patients admitted to the ED in 2014 were resuscitated according to 2010 AHA CPR guidelines, while those admitted to the ED in 2015 were resuscitated according to current ERC CPR guidelines. Results: The study population comprised 48 male and 35 female patients. Of the 2010 AHA guideline patients, 39.21% experienced pulmonary contusion, while 54.83% of 2015 ERC guideline patients had pulmonary contusion. It was found that 11.76% of 2010 AHA guideline patients and 3.22% of 2015 ERC guideline patients had pneumothorax, while 9.8% of 2010 AHA guideline patients and 12.9% of 2015 ERC guideline patients experienced hemothorax. Incidence rates of lung contusion, pneumothorax, and hemothorax were higher in patients with rib fractures. Conclusion: In this study, traumatic thoracic complications were investigated in patients with ROSC after CPR. The incidence of CRP-related injuries did not decrease on application of the new 2015 ERC CPR guideline recommendations. The most common injury in this study was rib fracture, followed by sternal fracture, lung contusion, hemothorax, and pneumothorax. Statistically, rib fracture had a positive relationship with lung contusion, hemothorax, and pneumothorax.

How to avoid and manage a pneumothorax

Pneumothorax is one of the most frequent complications during percutaneous central vascular cannulation. When choosing a site for central vascular access, the internal jugular vein is preferable to other vessels, for the lower frequency of related complications, including pneumothorax. This review intends to summarize the current state of the art on how to avoid and, if it occurs, to manage this rare but relevant complication. In order to prevent pneumothorax, as well as other relevant complications of central vein cannulation, it is advisable to use ultrasound guidance whenever possible. If pneumothorax occurs, it is important to recognize its signs and symptoms. To exclude the presence of asymptomatic pneumothorax, in the normal clinical routine a chest X-ray should be obtained within 4 hours from the procedure of central vein cannulation of subclavian and internal jugular veins. If promptly recognized, pneumothorax can be managed quickly and in a relatively easy way. Depending on its size and symptoms, and in particular when a tension pneumothorax is supected, treatment can vary from simple observation to a chest tube insertion or, in the latter case, to an emergency thoracentesis needle insertion in the pleural space.

Analyzing Effectiveness of Routine Pleural Drainage After Nuss Procedure: A Randomized Study

BACKGROUND

The routine use of postoperative pleural cavity drainage after the Nuss procedure is not widely accepted, and its limited use depends on experience. This study analyzed the influence of pleural drainage in the surgical treatment of patients with pectus excavatum on the prevention of pneumothorax and the efficacy of using drainage after a corrective operation.

METHODS

From November 2013 to May 2015, 103 consecutive patients with pectus excavatum, aged 11 to 39 years, underwent surgical treatment by the Nuss procedure. Patients were prospectively randomized into two groups. In 58 patients, a 28F chest tube was routinely introduced into the right pleural cavity during procedure for 2 consecutive days (group I). In the remaining 45 patients, the drain was not inserted (group II).

RESULTS

No statistically significant differences were found between the study groups, including sex, age, body mass index, or clinical subjective and objective factors in the preoperative evaluation. Group II manifested more complications in the early postoperative period; however, this was not statistically significant (group I vs group II; p = 0.0725). Pneumothorax requiring additional chest tube placement was statistically significant (group I vs group II; p = 0.0230). Other complications were also more frequent among patients from group II, although this did not reach statistical significance. Follow up was 22.9 ± 6.4 months.

CONCLUSIONS

Routine drainage of the pleural cavity during the Nuss procedure significantly reduces the incidence of postoperative pneumothorax and should be considered as a routine procedure.

Pulmonary Intraparenchymal Blood Patching Decreases the Rate of Pneumothorax-Related Complications following Percutaneous CT-Guided Needle Biopsy

PURPOSE

To investigate whether an autologous intraparenchymal blood patch (IPB) reduces the rate of pneumothorax-related complications associated with computed tomography (CT)-guided lung biopsies.

MATERIALS AND METHODS

This study included 834 patients: 482 who received an IPB and 352 who did not. Retrospective review was performed of all CT-guided lung biopsies performed at a single institution between August 2006 and September 2013. Patients were excluded if no aerated lung was crossed. The rate of pneumothorax, any associated intervention (eg, catheter placement, aspiration), chest tube placement, and chest tube replacement requiring hospital admission were compared by linear and multiple regression analysis.

RESULTS

Patients who received an IPB had a significantly lower rate of pneumothorax (145 of 482 [30%] vs 154 of 352 [44%]; P < .0001), pneumothorax-related intervention (eg, catheter aspiration, pleural blood patch, chest tube placement; 43 of 482 [8.9%] vs 85 of 352 [24.1%]; P < .0001), and chest tube placement along with other determinants requiring hospital admission (18 of 482 [3.7%] vs 27 of 352 [7.7%]; P < .0001). No complications related to the IPB were noted in the study group.

CONCLUSIONS

Autologous IPB placement is associated with a decreased rate of pneumothorax and associated interventions, including chest tube placement and hospital admission, after CT-guided lung biopsies, with no evidence of any adverse effects. These results suggest that an IPB is safe and effective and should be considered when aerated lung is traversed while performing a CT-guided lung biopsy.

The use of ultrasound during and after central venous catheter insertion versus conventional chest X-ray after insertion of a central venous catheter

BACKGROUND

After insertion of a central venous catheter (CVC) a conventional chest X-ray (CXR) is usually taken to check for complications and correct position. Ultrasound might be equally effective as CXR and is less time consuming. We studied the use of ultrasound versus CXR after insertion of a CVC in general ward patients.

METHODS

General ward patients in need of a CVC were included. CVCs were inserted under direct ultrasound guidance. After insertion, ultrasound was performed and compared with CXR to check for complications and position. The waiting time for CXR was noted.

RESULTS

In total, 53 patients were included. In 52/53 patients ultrasound was feasible. The results of ultrasound and CXR only differed in 3 of 53 patients. The sensitivity of ultrasound in detecting the correct CVC position was 98% (89.4-100%). No complications were detected (ultrasound or CXR). The median waiting time for CXR was 24.5 minutes.

CONCLUSIONS

Our study shows that an integral use of ultrasound during and after CVC insertion is effective in establishing that the CVC is correctly positioned and for identifying post-procedural complications in patients from the general ward when compared with CXR.

Role Of Clamping Tube Thoracostomy Prior To Removal In Non-Cardiac Thoracic Trauma

BACKGROUND

The frequently encountered thoracic trauma in surgical emergencies is a major cause of mortality and morbidity. Eighty percent of thoracic trauma can be managed by simple insertion of tube thoracostomy. Though guidelines for insertion are comprehensively explained in literature, an ideal algorithm for discontinuation is not available. A standard and safe defined protocol would eliminate hesitancy in confident removal among general surgeons. The objective of this study was to determine role of clamping trial prior to removal in terms of frequency of recurrent pneumothorax.

METHODS

This study was conducted in department of Surgery Combined military hospital/Military Hospital Rawalpindi from April 2013 to March 2014. Total 180 patients with blunt or penetrating thoracic trauma were included in the study. Chest tube (28-36 Fr) was inserted in Trauma centre under strict asepsis. Tubes were then connected to under water seal for minimum six hours. Patients were randomly divided in two equal groups (90 in each). In Group A, Clamping trial was given before attempting removal while in Group B, tube was removed immediately without clamping trial. Patients of both groups were observed two hourly for development of recurrent pneumothorax. Data was analysed using SPSS-18.

RESULTS

The comparison of frequency of recurrent pneumothorax in Group A (9 patients, 10%) and in Group B (4 patients, 4.5%) was not found to be statistically significant. (p-value 2.073).

CONCLUSIONS

Clamping trial is unnecessary prior to removal of tube thoracostomy in blunt and penetrating non-cardiac thoracic trauma in terms of recurrent pneumothorax.

Femoral Vein Cannulation in the Treatment of Osteomyelitis

OBJECTIVE

The main objective was to investigate the feasibil- ity of using the femoral vein for long-term venous access. This was accomplished in the course of treating osteomyelitis patients, using a combination of long-term (6 weeks), outpatient, intravenous (IV) an- tibiotics administered through a femoral central line. This was com- bined subsequently with the use of hyperbaric oxygen (HBO) therapy. Using the femoral vein for central venous access means there is no risk of creating an iatrogenic pneumothorax, which would prohibit the subsequent use of HBO therapy. In addition, the propitious nature of the groin skin flora, Propionibacteriaceae, seems less inclined to par- ticipate in biofilm production, the root cause of central line infections.

METHODS

The femoral central lines were all inserted in the operating room (OR) and handled like a regular outpatient surgery with a me- ticulous skin prep completed by experienced OR nurses. Experienced technicians assisted with the surgery. After insertion, the lines were then specially secured to prevent sliding. Vancomycin was adminis- tered preoperatively.

RESULTS

Surprisingly, femoral lines placed in this way remained free of infection for up to 70 days. Eight patients with Wagner stage 2 ulcers and underlying osteomyelitis were treated with a course of 6 weeks of vancomycin, followed by HBO therapy. A cure rate of 75% was achieved.

CONCLUSION

Femoral vein cannulation for antibi- otic administration is safe and effective in treating patients with osteo- myelitis. The lines should be placed in the OR with the help of skilled personnel. Femoral cannulation avoids the risk of pneumothorax, and the lines can be used for up to 70 days. By avoiding pneumothorax, the patients remain candidates for HBO therapy.

Improving and sustaining a reduction in iatrogenic pneumothorax through a multifaceted quality-improvement approach

BACKGROUND

The Agency for Healthcare Research and Quality has adopted iatrogenic pneumothorax (IAP) as a Patient Safety Indicator. In 2006, in response to a low performance ranking for IAP rate from the University Healthsystem Consortium (UHC), the authors established a multidisciplinary team to reduce our institution's IAP rate. Root-cause analysis found that subclavian insertion of central venous catheterization (CVC) was the most common procedure associated with IAP OBJECTIVE: Our short-term goal was a 50% reduction of both CVC-associated and all-cause IAP rates within 18 months, with long-term goals of sustained reduction.

DESIGN

Observational study.

SETTING

Academic tertiary care hospital.

PATIENTS

Consecutive inpatients from 2006 to 2014.

INTERVENTION

Our multifaceted intervention included: (1) clinical and documentation standards based on evidence, (2) cognitive aids, (3) simulation training, (4) purchase and deployment of ultrasound equipment, and (5) feedback to clinical services.

MEASUREMENTS

CVC-associated IAP, all-cause IAP rate.

RESULTS

We achieved both a short-term (years 2006 to 2008) and long-term (years 2006 to 2008-2014) reduction in our CVC-associated and all-cause IAP rates. Our short-term reduction in our CVC-associated IAP was 53% (P = 0.088), and our long-term reduction was 85% (P < 0.0001). Our short-term reduction in the all-cause IAP rate was 26% (P < 0.0001), and our long-term reduction was 61% (P < 0.0001).

CONCLUSIONS

A multidisciplinary team, focused on evidence, patient safety, and standardization, can use a set of multifaceted interventions to sustainably improve patient outcomes for several years after implementation. Our hospital was in the highest performance UHC quartile for all-cause IAP in 2012 to 2014.

The Treatment Results of a Standard Algorithm for Choosing the Best Entry Vessel for Intravenous Port Implantation

Vascular cutdown and echo guide puncture methods have its own limitations under certain conditions. There was no available algorithm for choosing entry vessel. A standard algorithm was introduced to help choose the entry vessel location according to our clinical experience and review of the literature. The goal of this study is to analyze the treatment results of the standard algorithm used to choose the entry vessel for intravenous port implantation.During the period between March 2012 and March 2013, 507 patients who received intravenous port implantation due to advanced chemotherapy were included into this study. Choice of entry vessel was according to standard algorithm. All clinical characteristic factors were collected and complication rate and incidence were further analyzed.Compared with our clinical experience in 2006, procedure-related complication rate declined from 1.09% to 0.4%, whereas the late complication rate decreased from 19.97% to 3.55%. No more pneumothorax, hematoma, catheter kinking, fractures, and pocket erosion were identified after using the standard algorithm. In alive oncology patients, 98% implanted port could serve a functional vascular access to fit therapeutic needs.This standard algorithm for choosing the best entry vessel is a simple guideline that is easy to follow. The algorithm has excellent efficiency and can minimize complication rates and incidence.

Modifying Post-Operative Medical Care after EBV Implant May Reduce Pneumothorax Incidence

Objective

Endoscopic lung volume reduction (ELVR) with valves has been shown to improve COPD patients with severe emphysema. However, a major complication is pneumothoraces, occurring typically soon after valve implantation, with severe consequences if not managed promptly. Based on the knowledge that strain activity is related to a higher risk of pneumothoraces, we asked whether modifying post-operative medical care with the inclusion of strict short-term limitation of strain activity is associated with a lower incidence of pneumothorax.

Methods

Seventy-two (72) emphysematous patients without collateral ventilation were treated with bronchial valves and included in the study. Thirty-two (32) patients received standard post-implantation medical management (Standard Medical Care (SMC)), and 40 patients received a modified medical care that included an additional bed rest for 48 hours and cough suppression, as needed (Modified Medical Care (MMC)).

Results

The baseline characteristics were similar for the two groups, except there were more males in the SMC cohort. Overall, ten pneumothoraces occurred up to four days after ELVR, eight pneumothoraces in the SMC, and only two in the MMC cohorts (p=0.02). Complicated pneumothoraces and pneumothoraces after upper lobe treatment were significantly lower in MMC (p=0.02). Major clinical outcomes showed no significant differences between the two cohorts.

Conclusions

In conclusion, modifying post-operative medical care to include bed rest for 48 hours after ELVR and cough suppression, if needed, might reduce the incidence of pneumothoraces. Prospective randomized studies with larger numbers of well-matched patients are needed to confirm the data.

[Permanent cardiac pacing in women--light and shadow]

Permanent cardiac pacing has survived a sharp increase in quality improvement and frequency of usage. Nowadays particular aspects of this method of treatment are being considered. In this paper distinctiveness of women population treated by permanent pacing is discussed. Indications for heart pacing in women appear at a later age than in men. Moreover, women remain longer in follow-up, therefore their prognosis is better. The most serious late pacing complications, i.e., infections are less frequent in women. However, implantations procedures seem to be more difficult in female gender, most probably due to a smaller body size, especially of afferent veins. This leads to a higher periprocedural complication rate and refers especially to endocardial lead implantation, which in women is connected with double risk of pneumothorax. Late complications of permanent pacing are effectively treated by transvenous lead extraction. Female gender has been demonstrated as an independent risk factor of extraction failure. It seems that reasonable qualification for pacemaker implantations and leaving the procedures in the hands of experienced operators will strengthen the "light side" and limit the "dark side" of this therapy in women.

Does this patient have an exudative pleural effusion? The Rational Clinical Examination systematic review

IMPORTANCE

Thoracentesis is performed to identify the cause of a pleural effusion. Although generally safe, thoracentesis may be complicated by transient hypoxemia, bleeding, patient discomfort, reexpansion pulmonary edema, and pneumothorax.

OBJECTIVE

To identify the best means for differentiating between transudative and exudative effusions and also to identify thoracentesis techniques for minimizing the risk of complications by performing a systematic review the evidence.

DATA SOURCES

We searched The Cochrane Library, MEDLINE, and Embase from inception to February 2014 to identify relevant studies.

STUDY SELECTION

We included randomized and observational studies of adult patients undergoing thoracentesis that examined diagnostic tests for differentiating exudates from transudates and evaluated thoracentesis techniques associated with a successful procedure with minimal complications.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently appraised study quality and extracted data from studies of laboratory diagnosis of pleural effusion for calculation of likelihood ratios (LRs; n = 48 studies) and factors affecting adverse event rates (n = 37 studies).

RESULTS

The diagnosis of an exudate was most accurate if cholesterol in the pleural fluid was greater than 55 mg/dL (LR range, 7.1-250), lactate dehydrogenase (LDH) was greater than 200 U/L (LR, 18; 95% CI, 6.8-46), or the ratio of pleural fluid cholesterol to serum cholesterol was greater than 0.3 (LR, 14; 95% CI, 5.5-38). A diagnosis of exudate was less likely when all Light's criteria (a ratio of pleural fluid protein to serum protein >0.5, a ratio of pleural fluid LDH to serum LDH >0.6, or pleural fluid LDH >two-thirds the upper limit of normal for serum LDH) were absent (LR, 0.04; 95% CI, 0.02-0.11). The most common complication of thoracentesis was pneumothorax, which occurred in 6.0% of cases (95% CI, 4.0%-7.0%). Chest tube placement was required in 2.0% of procedures (95% CI, 0.99%-2.9%) in which a patient was determined to have radiographic evidence of a pneumothorax. With ultrasound, a radiologist's marking the needle insertion site was not associated with decreased pneumothorax events (skin marking vs no skin marking odds ratio [OR], 0.37; 95% CI, 0.08-1.7). Use of ultrasound by any experienced practitioner also was not associated with decreased pneumothorax events (OR, 0.55; 95% CI, 0.06-5.3).

CONCLUSIONS AND RELEVANCE

Light's criteria, cholesterol and pleural fluid LDH levels, and the pleural fluid cholesterol-to-serum ratio are the most accurate diagnostic indicators for pleural exudates. Ultrasound skin marking by a radiologist or ultrasound-guided thoracentesis were not associated with a decrease in pneumothorax events.

Ultrasound guidance reduces pneumothorax rate and improves safety of thoracentesis in malignant pleural effusion: report on 445 consecutive patients with advanced cancer

BACKGROUND

Malignant pleural effusion (MPE) is an extremely common problem affecting cancer patients, and thoracentesis is an essential procedure in an attempt to delineate the etiology of the fluid collections and to relieve symptoms in affected patients. One of the most common complications of thoracentesis is pneumothorax, which has been reported to occur in 20% to 39% of thoracenteses, with 15% to 50% of patients with pneumothorax requiring tube thoracostomy.The present study was carried out to assess whether thoracenteses in cancer patients performed with ultrasound (US) guidance are associated with a lower rates of pneumothorax and tube thoracostomy than those performed without US guidance.

METHODS

A total of 445 patients were recruited in this retrospective study. The medical records of 445 consecutive patients with cancer and MPE evaluable for this study, undergoing thoracentesis at the Oncology-Hematology and Internal Medicine Departments, Piacenza Hospital (Italy) were reviewed.

RESULTS

From January 2005 to December 2011, in 310 patients (69.66%) thoracentesis was performed with US guidance and in 135 (30.34%) without it. On post-thoracentesis imaging performed in all these cases, 15 pneumothoraces (3.37%) were found; three of them (20%) required tube thoracostomy. Pneumothorax occurred in three out of 310 procedures (0.97%) performed with US guidance and in 12 of 135 procedures (8.89%) performed without it (P<0.0001). It must be emphasized that in all three patients with pneumothorax requiring tube thoracostomy, thoracentesis was performed without US guidance.

CONCLUSIONS

The routine use of US guidance during thoracentesis drastically reduces the rate of pneumothorax and tube thoracostomy in oncological patients, thus improving safety as demonstrated in this study.

The rising burden of serious thoracic trauma sustained by motorcyclists in road traffic crashes

In many countries increased on-road motorcycling participation has contributed to increased motorcyclist morbidity and mortality over recent decades. Improved helmet technologies and increased helmet wearing rates have contributed to reductions in serious head injuries, to the point where in many regions thoracic injury is now the most frequently occurring serious injury. However, few advances have been made in reducing the severity of motorcyclist thoracic injury. The aim of the present study is to provide needed information regarding serious motorcyclist thoracic trauma, to assist motorcycling groups, road safety advocates and road authorities develop and prioritise counter-measures and ultimately reduce the rising trauma burden. For this purpose, a data collection of linked police-reported and hospital data was established, and considerable attention was given to establishing a weighting procedure to estimate hospital cases not reported to police and fatal cases not admitted to hospital. The resulting data collection of an estimated 19,979 hospitalised motorcyclists is used to provide detailed information on the nature, incidence and risk factors for thoracic trauma. Over the last decade the incidence of motorcyclist serious thoracic injury has more than doubled in the population considered, and by 2011 while motorcycles comprised 3.2% of the registered vehicle fleet, one quarter of road traffic-related serious thoracic trauma cases treated in hospitals were motorcyclists. Motor-vehicle collisions, fixed object collisions and non-collision crashes were fairly evenly represented amongst these cases, while older motorcyclists were over-represented. Several prevention strategies are identified and discussed.

[The effectiveness of the valve bronchial occlusion in case of bronchopleural fistulas]

The experience of endobronchial valve «Medlung" installation in 24 patients with bronchopleural fistula was summarized in the article. In 18 (75%) patients the cause of bronchopleural fistula was purulent - destructive processes in the lungs, including the associated trauma in 4 (22.2%) patients, pneumonia in 14 (77.8%) patients. In 3 (12.5%) cases the cause of the bronchopleural fistula was the lung tumors of different localization and in 3 (12.5%) cases - idiopathic pulmonary fibrosis. Reasonable use of endobronchial valve in patients with bronchopleural fistula provides a persistent separation of the fistula and lets to avoid extensive, traumatic operations.

[Etiology and prevention of neonatal pneumothorax]

OBJECTIVE

To investigate the risk factors and preventative measures for neonatal pneumothorax.

METHODS

Retrospective analysis was performed on the clinical data of 2286 neonates who were hospitalized in the neonatal intensive care unit between October 2010 and November 2011, and a case-control study was conducted to analyze the risk factors and preventative measures for neonatal pneumothorax.

RESULTS

The incidence of pneumothorax among the neonates was 1.57% (36/2286), and it was significantly higher in full-term infants than in preterm infants (23/1033 vs 13/1253, P=0.023). Logistic regression analysis indicated that cesarean section, neonatal respiratory distress syndrome (NRDS), wet lung, pneumonia and mechanical ventilation were the independent risk factors for neonatal pneumothorax (odds ratios=7.951, 6.090, 7.898, 6.272 and 4.389; P<0.05 for all). The higher the peak inspiratory pressure (PIP) during mechanical ventilation, the higher the incidence of neonatal pneumothorax (P<0.001). Pulmonary surfactant reduced the incidence of pneumothorax among neonates with NRDS (2.9% vs 10.1%; P=0.006).

CONCLUSIONS

Neonatal pneumothorax occurs mostly in full-term infants. Cesarean section, NRDS, wet lung, pneumonia and mechanical ventilation are closely associated with neonatal pneumothorax. Strict management of indications for cesarean section, keeping PIP at a low level during mechanical ventilation, and use of pulmonary surfactant are helpful in preventing neonatal pneumothorax.

Simple aspiration and drainage and intrapleural minocycline pleurodesis versus simple aspiration and drainage for the initial treatment of primary spontaneous pneumothorax: an open-label, parallel-group, prospective, randomised, controlled trial

BACKGROUND

Simple aspiration and drainage is a standard initial treatment for primary spontaneous pneumothorax, but the rate of pneumothorax recurrence is substantial. We investigated whether additional minocycline pleurodesis after simple aspiration and drainage reduces the rate of recurrence.

METHODS

In our open-label, parallel-group, prospective, randomised, controlled trial at two hospitals in Taiwan, patients were aged 15-40 years and had a first episode of primary spontaneous pneumothorax with a rim of air greater than 2 cm on chest radiographs, complete lung expansion without air leakage after pigtail catheter drainage, adequate haematological function, and normal renal and hepatic function. After simple aspiration and drainage via a pigtail catheter, patients were randomly assigned (1:1) to receive 300 mg of minocycline pleurodesis or no further treatment (control group). Randomisation was by computer-generated random numbers in sealed envelopes. Our primary endpoint was rate of pneumothorax recurrence at 1 year. This trial is registered with ClinicalTrials.gov (NCT00418392).

FINDINGS

Between Dec 31, 2006, and June 30, 2012, 214 patients were randomly assigned-106 to the minocycline group and 108 to the control group (intention-to-treat population). Treatment was unsuccessful within 7 days of randomisation in 14 patients in the minocycline group and 20 patients in the control group. At 1 year, pneumothoraces had recurred in 31 of 106 (29·2%) patients in the minocycline group compared with 53 of 108 (49·1%) in the control group (p=0·003). We noted no procedure-related complications in either group.

INTERPRETATION

Simple aspiration and drainage followed by minocycline pleurodesis is a safe and more effective treatment for primary spontaneous pneumothorax than is simple aspiration and drainage only. Minocycline pleurodesis should be an adjunct to standard treatment for primary spontaneous pneumothorax.

FUNDING

Department of Health and National Science Council, Taiwan.

Preoperative physical therapy for elective cardiac surgery patients

BACKGROUND

After cardiac surgery, physical therapy is a routine procedure delivered with the aim of preventing postoperative pulmonary complications.

OBJECTIVES

To determine if preoperative physical therapy with an exercise component can prevent postoperative pulmonary complications in cardiac surgery patients, and to evaluate which type of patient benefits and which type of physical therapy is most effective.

SEARCH METHODS

Searches were run on the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library (2011, Issue 12 ); MEDLINE (1966 to 12 December 2011); EMBASE (1980 to week 49, 2011); the Physical Therapy Evidence Database (PEDro) (to 12 December 2011) and CINAHL (1982 to 12 December 2011).

SELECTION CRITERIA

Randomised controlled trials or quasi-randomised trials comparing preoperative physical therapy with no preoperative physical therapy or sham therapy in adult patients undergoing elective cardiac surgery.

DATA COLLECTION AND ANALYSIS

Data were collected on the type of study, participants, treatments used, primary outcomes (postoperative pulmonary complications grade 2 to 4: atelectasis, pneumonia, pneumothorax, mechanical ventilation > 48 hours, all-cause death, adverse events) and secondary outcomes (length of hospital stay, physical function measures, health-related quality of life, respiratory death, costs). Data were extracted by one review author and checked by a second review author. Review Manager 5.1 software was used for the analysis.

MAIN RESULTS

Eight randomised controlled trials with 856 patients were included. Three studies used a mixed intervention (including either aerobic exercises or breathing exercises); five studies used inspiratory muscle training. Only one study used sham training in the controls. Patients that received preoperative physical therapy had a reduced risk of postoperative atelectasis (four studies including 379 participants, relative risk (RR) 0.52; 95% CI 0.32 to 0.87; P = 0.01) and pneumonia (five studies including 448 participants, RR 0.45; 95% CI 0.24 to 0.83; P = 0.01) but not of pneumothorax (one study with 45 participants, RR 0.12; 95% CI 0.01 to 2.11; P = 0.15) or mechanical ventilation for > 48 hours after surgery (two studies with 306 participants, RR 0.55; 95% CI 0.03 to 9.20; P = 0.68). Postoperative death from all causes did not differ between groups (three studies with 552 participants, RR 0.66; 95% CI 0.02 to 18.48; P = 0.81). Adverse events were not detected in the three studies that reported on them. The length of postoperative hospital stay was significantly shorter in experimental patients versus controls (three studies with 347 participants, mean difference -3.21 days; 95% CI -5.73 to -0.69; P = 0.01). One study reported a reduced physical function measure on the six-minute walking test in experimental patients compared to controls. One other study reported a better health-related quality of life in experimental patients compared to controls. Postoperative death from respiratory causes did not differ between groups (one study with 276 participants, RR 0.14; 95% CI 0.01 to 2.70; P = 0.19). Cost data were not reported on.

AUTHORS' CONCLUSIONS

Evidence derived from small trials suggests that preoperative physical therapy reduces postoperative pulmonary complications (atelectasis and pneumonia) and length of hospital stay in patients undergoing elective cardiac surgery. There is a lack of evidence that preoperative physical therapy reduces postoperative pneumothorax, prolonged mechanical ventilation or all-cause deaths.

Neonatal air leak syndrome and the role of high-frequency ventilation in its prevention

Air leak syndrome includes pulmonary interstitial emphysema, pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum, subcutaneous emphysema, and systemic air embolism. The most common cause of air leak syndrome in neonates is inadequate mechanical ventilation of the fragile and immature lungs. The incidence of air leaks in newborns is inversely related to the birth weight of the infants, especially in very-low-birth-weight and meconium-aspirated infants. When the air leak is asymptomatic and the infant is not mechanically ventilated, there is usually no specific treatment. Emergent needle aspiration and/or tube drainage are necessary in managing tension pneumothorax or pneumopericardium with cardiac tamponade. To prevent air leak syndrome, gentle ventilation with low pressure, low tidal volume, low inspiratory time, high rate, and judicious use of positive end expiratory pressure are the keys to caring for mechanically ventilated infants. Both high-frequency oscillatory ventilation (HFOV) and high-frequency jet ventilation (HFJV) can provide adequate gas exchange using extremely low tidal volume and supraphysiologic rate in neonates with acute pulmonary dysfunction, and they are considered to have the potential to reduce the risks of air leak syndrome in neonates. However, there is still no conclusive evidence that HFOV or HFJV can help to reduce new air leaks in published neonatal clinical trials. In conclusion, neonatal air leaks may present as a thoracic emergency requiring emergent intervention. To prevent air leak syndrome, gentle ventilations are key to caring for ventilated infants. There is insufficient evidence showing the role of HFOV and HFJV in the prevention or reduction of new air leaks in newborn infants, so further investigation will be necessary for future applications.

Efficacy of computed tomography-guided fine needle aspiration in diagnosis of lung mass by trained internists

OBJECTIVE

To determine the efficacy of Computed Tomography (CT)-guided fine needle Aspiration (FNA) in diagnosis of lung masses by trained internists including factors affecting the adequacy of specimens and occurrence rate of complications.

MATERIAL AND METHOD

96 patients, aged 25-86 years old underwent CT-guided FNA of thoracic lesions by internists who had been trained for this procedure at the Central Chest Institute of Thailand during March 2007-2008. Demographic data, procedure success and adequacy of specimens for cytological evaluation were summarized including other factors-size and depth of lesion, condition of emphysema and complications of procedure.

RESULTS

Success of procedure was 97.9%. Adequacy of specimen was 94.7%. Occurrence of pneumothorax was 19 out of 96 cases (19.8%). And 1 case needed to insert inter costal drainage (1.1%). Hemoptysis after procedure was 1.06%. Besides, larger than 3 cm in diameter of lesion presented satisfied specimens more than that of the smaller one. Pneumothorax is the most common complication, which revealed a statistically significant with emphysema around mass.

CONCLUSION

FNA is an effective and useful tool in diagnosis of pulmonary lesions for trained internists. Success of procedure and adequacy of specimen for cytological evaluation are considerably high and low complications occurred.

[Significance of drains in surgery]

Placing drains is one the most common procedures following operations in surgical disciplines. The indication for placing a drain is, however, usually based on a traditional belief rather than being evidence-based. This paper presents an overview of the literature regarding the indications and the evidence level for placing drains following operations in visceral, vascular, thoracic and orthopeedic surgery as well as traumatology. In visceral surgery the indications for placing drains could be clarified over the past decades but in other surgical fields the level of evidence needs further investigation and clarification through future studies. The available data suggest that in most cases a prophylactic drainage can be avoided. In addition, drains may lead to increased morbidity and higher treatment costs.

Supraclavicular brachial plexus blocks: review and current practice

This article reviews the possible revival of the supraclavicular brachial plexus blockade due to the use of ultrasound guidance. The brachial plexus is a complex network of nerves, extending from the neck to the axilla, which supplies motor and sensory fibers to the upper extremity. Understanding the complexities of the formation and structure of the brachial plexus remains a cornerstone for effective regional anaesthesia. On the level of the supraclavicular fossa, the plexus is most compactly arranged. The supraclavicular approach of the brachial plexus has a high success rate including blockade of the ulnar and musculocutaneous nerve, which can be missed respectively with the interscalene and axillary approach. However, because of the proximity of the pleura, most anaesthesiologists have been reluctant to perform this supraclavicular approach. The introduction of ultrasound guidance techniques not only reduces the possible risk of pneumothorax but also allows a faster onset time of the block with a reduction of the local anaesthetic dose. This makes the supraclavicular approach a valuable alternative to the axillary, interscalene and infraclavicular approach for upper limb surgery.

[Risk factors of pneumothorax and hemorrhage in lung biopsy: a single institution experience]

OBJECTIVES

CT-guided transthoracic lung biopsy is widely used in pulmonary lesions diagnosis. This technique rarely entails severe complications such as pneumothorax and pulmonary hemorrhage which call for adequate candidates screening. The aim of our study is to statistically assess risk factors related to these two main complications, and determine the best diagnostic workup.

MATERIALS AND METHODS

This retrospective study includes 110 patients who underwent CT-guided transthoracic biopsy of a pulmonary lesion. Rates of pneumothorax and pulmonary hemorrhage, as well as their severity, were evaluated, and a correlation with factors related to patients, lesions and biopsy technique were statistically analyzed.

RESULTS

Higher rates of complications are significantly found with multiple punctures (pneumothorax risk multiplied by 7.4), longer intra-parenchymal needle tract (5 and 7% higher risk of pneumothorax and hemorrhage for every 1 mm increase in depth), and with smaller lesions (2 and 5% lower risk respectively for pneumothorax and hemorrhage for every 1 cm increase in lesion size). The presence of an interposing rib is associated with a higher rate of hemorrhage.

CONCLUSION

Transthoracic lung biopsy is a minimally invasive technique. However, the presence of associated risk factors must lead to consider another diagnostic method.

Pleural controversy: aetiology of pneumothorax

Pneumothoraces are classified as spontaneous, traumatic and iatrogenic. Spontaneous pneumothoraces that occur without recognized lung disease are termed primary spontaneous pneumothoraces (PSP), whereas those that occur due to an underlying lung disease are termed secondary spontaneous pneumothoraces. The aetiology of secondary, traumatic or iatrogenic pneumothoraces is not usually debated. However, the aetiology of PSP is potentially controversial and often debated. Therefore, PSP is the focus of this article. There are several purported causes, which include blebs, bullae, emphysema-like changes (ELC) and pleural porosity. The controversy is valid because of the importance of recurrence prevention. This article reviews the current available evidence for the causes of PSP. The causes of PSP are likely a combination ELC, pleural porosity and other potential factors.

Management and prevention of spontaneous pneumothorax using pleurodesis in Hong Kong

BACKGROUND

The practice of pleurodesis for the management and prevention of spontaneous pneumothorax (SP) is uncertain.

DESIGN

A retrospective multicentre analysis of patients admitted to 12 hospitals in Hong Kong with SP in 2004 and who subsequently underwent pleurodesis for the same episode.

RESULTS

Pleurodesis was performed in 394 episodes. Initial medical chemical pleurodesis was performed for 258 (65.5%) patients ('initial medical group'), while 136 (34.5%) underwent initial surgical pleurodesis ('initial surgical group'). Secondary spontaneous pneumothorax (SSP; 237 episodes, 60.2%) was the most common indication for pleurodesis; it was also performed after a first episode of primary spontaneous pneumothorax (PSP) in 22 episodes (5.6%). Tetracycline derivatives (172 episodes, 66.7%) were the most popular sclerosing agents in the initial medical group. Those in the initial medical group were older and were more likely to be males, have SSP, chronic obstructive pulmonary disease and a history of past pleurodesis (P < 0.05) compared to the initial surgical group. Compared to the tetracycline group, more patients who initially received talc slurry had the procedure performed by surgeons, had larger (≥2 cm) pneumothorax or required suction during initial drainage (P < 0.05).

CONCLUSIONS

Despite the availability of international guidelines, there is considerable variation in pleurodesis for SP.