Observational management of penetrating occult pneumothoraces: Outcomes and risk factors for interval tube thoracostomy placement

BACKGROUND

Guidelines for penetrating occult pneumothoraces (OPTXs) are based on blunt injury. Further understanding of penetrating OPTX pathophysiology is needed. In observational management of penetrating OPTX, we hypothesized that specific clinical and radiographic features may be associated with interval tube thoracostomy (TT) placement. Our aims were to (1) describe OPTX occurrence in penetrating chest injury, (2) determine the rate of interval TT placement in observational management and clinical outcomes compared with immediate TT placement, and (3) describe risk factors associated with failure of observational management.

METHODS

Penetrating OPTX patients presenting to our level 1 trauma center from 2004 to 2019 were reviewed. Occult pneumothorax was defined as a pneumothorax on chest computed tomography but not on chest radiograph. Patient groups included immediate TT placement versus observation. Clinical outcomes compared were TT duration and complications, need for additional thoracic procedures, length of stay (LOS), and disposition. Clinical and radiographic factors associated with interval TT placement were determined by multivariable regression.

RESULTS

Of 629 penetrating pneumothorax patients, 103 (16%) presented with OPTX. Thirty-eight patients underwent immediate TT placement, and 65 were observed. Twelve observed patients (18%) needed interval TT placement. Regardless of initial management strategy, TT placement was associated with longer LOS and more chest radiographs. Chest injury complications and outcomes were similar. Factors associated with increased odds of interval TT placement included Chest Abbreviated Injury Scale score of ≥4 (adjusted odds ratio [aOR], 7.38 [95% confidence interval, 1.43-37.95), positive pressure ventilation (aOR, 7.74 [1.07-56.06]), concurrent hemothorax (aOR, 6.17 [1.08-35.24]), and retained bullet fragment (aOR, 11.62 [1.40-96.62]) (all p < 0.05).

CONCLUSION

The majority of patients with penetrating OPTX can be successfully observed with improved clinical outcomes (LOS, avoidance of TT complications, reduced radiation). Interval TT intervention was not associated with risk for adverse outcomes. In patients undergoing observation, specific clinical factors (chest injury severity, ventilation) and imaging features (hemothorax, retained bullet) are associated with increased odds for interval TT placement, suggesting need for heightened awareness in these patients.

LEVEL OF EVIDENCE

Prognostic, level IV.

Intrapleural use of urokinase and DNase in pleural infections managed with repeated thoracentesis: A comparative cohort study

Introduction

Evacuation of infected fluid in pleural infections is essential. To date, the use of an intrapleural fibrinolytic agent such as urokinase and DNase has not yet been assessed in infections managed by repeated therapeutic thoracentesis (RTT).

Methods

We performed a retrospective comparative study of two successive cohorts of consecutive patients with pleural infections from 2001 to 2018. Between 2001 and 2010, patients had RTT with intrapleural urokinase (RTT-U). After 2011, patients received intrapleural urokinase and DNase with RTT (RTT-UD). Data were collected through a standardized questionnaire.

Results

One hundred and thirty-three patients were included: 93 were men and the mean age was 59 years (standard deviation 17.2). Eighty-one patients were treated with a combination of intrapleural urokinase and DNase, and 52 were treated with intrapleural urokinase only. In the RTT-UD, RTT failure occurred in 14 patients (17%) compared to 10 (19%) in the RTT-U group (P = 0.82). There was no difference between the two groups in intensive care unit admission, surgical referrals or in-hospital mortality. RTT-UD was associated with faster time to apyrexia (aOR = 0.51, 95%CI [0.37–0.72]), a reduced length of hospital stay (aOR = 0.61, 95%CI [0.52–0.73]) and a higher volume of total pleural fluid retrieved (aOR = 1.38, 95%CI [1.02–1.88]). Complications were rare with only one hemothorax in the RTT-UD group and no pneumothorax requiring drainage in either group.

Conclusion

Compared to urokinase only, intrapleural use of urokinase and DNase in RTT was associated with quicker defervescence, shorter hospital stay and increased volumes of pleural fluid drained. Randomized controlled trials evaluating urokinase and DNase with RTT technique would be required to confirm these results.

Evaluation of the position of the needle tip during thoracentesis: Experimental study

INTRODUCTION

Thoracentesis is performed to both diagnose and/or treat pleural effusion, and several important complications of thoracentesis are occasionally observed. To assess precise thoracentesis procedures, we evaluated the position of the needle tip during thoracentesis by using a thoracentesis unit, comparing experienced and inexperienced groups.

METHODS

Twenty eight physicians (19 board-certified pulmonologists as an experienced group and the remaining 9 as an inexperienced group) participated at Fukujuji Hospital in January 2021. All participants performed 2 punctures with a handmade thoracentesis unit and measured the needle's angle to the midline.

RESULTS

The median distance from the needle tip to the midline when the needle was inserted 5 cm (D5) was 0.47 cm (range 0.06-1.05), and the median difference between D5 on the 1st puncture (D51st) and D5 on the 2nd puncture (D52nd) was 0.22 cm (range 0.00-0.69). D5 was shorter in the experienced group than in the inexperienced group (median 0.40 cm (range 0.06-0.66) vs 0.58 cm (range 0.44-1.05), P < .001). There were no significant differences in the D51st and D52nd distances between the experienced and inexperienced groups (median 0.22 cm (range 0.00-0.40) vs 0.41 cm (range 0.04-0.69), P = .094). When 4 areas were divided by the x-axis and y-axis, 32 punctures (55.2%) deviated to the right-upper quadrant, and 25 (86.2%) of participants made the 1st puncture and 2nd puncture in the same direction.

CONCLUSIONS

All doctors should know that the needle direction might shift by approximately 1 cm, and more than half of the practitioners punctured towards the upper right.

A Review of Symptoms and Complications of Ultrasound Assisted Thoracentesis in the First Specialist Pleural Clinic in Israel

BACKGROUND

Our 1600-bed teaching hospital opened the first physician-led specialist pleural service in Israel in November 2016. Thoracentesis is one of the frequently performed procedures in clinic.

OBJECTIVES

To review the incidence of thoracentesis-related symptoms, complications, and risk factors in a specialist pleural clinic.

METHODS

Prospective analysis was conducted of 658 ultrasound-assisted thoracenteses between November 2016 and November 2019. Data were collected on patient demographics, clinical characteristics, procedural aspects, symptoms, complications, and additional interventions required.

RESULTS

Of the procedures, 24% were accompanied by a reported symptom of any intensity or duration. Cough and chest discomfort were noted in 56.4% and 52% of these cases, respectively. Large-volume drainage was associated with symptoms (P = 0.002). Ultrasound-estimated effusion volume before drainage predicted pain (P = 0.001) and pneumothorax (P = 0.021). Of 8 cases of pneumothorax, 6 were due to non-expandable lung. Two patients were hospitalized (0.3%), and one required a chest drain.

CONCLUSIONS

Symptoms are a common feature of thoracentesis even when performed by experienced operators in ideal settings. Complications, however, are rare when the procedure is performed with bedside ultrasound and attention is paid to patient-reported symptoms and volume drained. Specialist pleural clinics provide a good model for a standardized approach to safe performance of this common procedure.

Development and validation of a novel scoring system developed from a nomogram to identify malignant pleural effusion

BACKGROUND

This study aimed to establish and validate a novel scoring system based on a nomogram for the differential diagnosis of malignant pleural effusion (MPE) and benign pleural effusion (BPE).

METHODS

Patients with PE and confirmed aetiology who underwent diagnostic thoracentesis were included in this study. One retrospective set (N = 1261) was used to develop and internally validate the predictive model. The clinical, radiological and laboratory features were collected and subjected to logistic regression analyses. The primary predictive model was displayed as a nomogram and then modified into a novel scoring system, which was externally validated in an independent set (N = 172).

FINDINGS

The novel scoring system was composed of fever (3 points), erythrocyte sedimentation rate (4 points), effusion adenosine deaminase (7 points), serum carcinoembryonic antigen (CEA) (4 points), effusion CEA (10 points) and effusion/serum CEA (8 points). With a cutoff value of 15 points, the area under the curve, specificity and sensitivity for identifying MPE were 0.913, 89.10%, and 82.63%, respectively, in the training set, 0.922, 93.48%, 81.51%, respectively, in the internal validation set and 0.912, 87.61%, 81.36%, respectively, in the external validation set. Moreover, this scoring system was exclusively applied to distinguish lung cancer with PE from tuberculous pleurisy and showed a favourable diagnostic performance in the training and validation sets.

INTERPRETATION

This novel scoring system was developed from a retrospective study and externally validated in an independent set based on six easily accessible clinical variables, and it exhibited good diagnostic performance for identifying MPE.

FUNDING

NFSC grants (no. 81572942, no. 81800094).

Role of early definitive management for newly diagnosed malignant pleural effusion related to lung cancer

BACKGROUND AND OBJECTIVE

The advent of effective anti-cancer therapy has brought about uncertainty on the benefit of early definitive measures for newly diagnosed MPE from lung cancer. This study aims to investigate the outcomes of MPE in this setting.

METHODS

Lung cancer patients with MPE at first presentation to a tertiary care hospital were followed up till death or censored from 2011 to 2018. Early MPE control measures included chemical pleurodesis or IPC before or shortly after oncological treatment. Predictors of time to MPE re-intervention were identified with Cox proportional hazard analyses.

RESULTS

Of the 509 records screened, 233 subjects were eligible. One hundred and twenty-seven subjects received oral targeted therapy as first-line treatment and 34 (26.8%) underwent early definitive MPE control measures. Early MPE control measures in addition to targeted therapy, as compared to targeted therapy alone, significantly reduced the subsequent need of MPE re-intervention (23.5% vs 53.8%, P = 0.002). Similar benefits from MPE control measures were found in groups receiving systemic anti-cancer therapy or best supportive care (0% vs 52%, P = 0.003; 18% vs 56.7%, P = 0.024, respectively). In the group with targetable mutations, both early MPE control measures (HR: 0.25, 95% CI: 0.12-0.53, P < 0.001) and the use of targeted therapy (HR: 0.22, 95% CI: 0.10-0.46, P < 0.001) were independently associated with longer time to MPE re-interventions.

CONCLUSION

Early MPE control measures in lung cancer has additional benefits on reducing the need and prolonging the time to MPE re-intervention, independent of anti-cancer therapies.

International Expert Consensus and Recommendations for Neonatal Pneumothorax Ultrasound Diagnosis and Ultrasound-guided Thoracentesis Procedure

Pneumothorax (PTX) represents accumulation of the air in the pleural space. A large or tension pneumothorax can collapse the lung and cause hemodynamic compromise, a life-threatening disorder. Traditionally, neonatal pneumothorax diagnosis has been based on clinical images, auscultation, transillumination, and chest X-ray findings. This approach may potentially lead to a delay in both diagnosis and treatment. The use of lung US in diagnosis of PTX together with US-guided thoracentesis results in earlier and more precise management. The recommendations presented in this publication are aimed at improving the application of lung US in guiding neonatal PTX diagnosis and management.

Pleural fluid lactate as a point-of-care adjunct diagnostic aid to distinguish tuberculous and complicated parapneumonic pleural effusions during initial thoracentesis: Potential use in a tuberculosis endemic setting

BACKGROUND

Tuberculous pleural effusions (TBEs) and parapneumonic pleural effusion (PPEs) have similar clinical presentations and fluid biochemistry. A pleural biopsy is usually required to diagnose TBE but complete fluid evacuation may not be necessary, contrasting with complicated PPE (CPPE). A point-of-care test that distinguishes between TBE and CPPE enables the appropriate procedures to be performed during the initial diagnostic thoracentesis. Lactate is a metabolic product measurable by a blood-gas analyzer. This study measured pleural fluid (Pf) lactate levels in TBE and compared them with those in PPE/CPPE. We hypothesized that Pf lactate would be significantly higher in PPE because of active metabolic activities than in TBE which is driven by delayed hypersensitivity.

METHODS

All patients undergoing an initial diagnostic thoracentesis over 18 months with Pf lactate measured using a calibrated point-of-care blood gas analyzer were assessed.

RESULTS

The diagnoses of the enrolled patients (n = 170) included TBE (n = 49), PPE (n = 47), malignancy (n = 63), and transudate (n = 11). Pf lactate level in TBE, median 3.70 (inter-quartile range 2.65-4.90) mmol/l, was significantly lower than in PPE and CPPE. In the subgroup of TBE and CPPE patients whose initial Pf pH and glucose could suggest either condition, Pf lactate was significantly higher in those with CPPE. Pf lactate (cutoff ≥7.25 mmol/l) had a sensitivity of 79.3%, specificity 100%, positive predictive value 100%, and negative predictive value 89.1% for discriminating CPPE from TBE (area under the curve 0.947, p < 0.001, 95% confidence interval 0.89-0.99).

CONCLUSIONS

Point-of-care Pf lactate measurements may have practical value in early separation of TBE or CPPE during initial thoracentesis, and warrants further investigation.

Pleural small cell carcinoma with massive pleural effusion: A case report

RATIONALE

Small cell carcinoma (SCC) occurs mostly in the lung, and small cell lung cancer accounts for 13% of newly diagnosed lung cancers. Only 2.5% of SCC occurs in extrapulmonary sites, and SCC of pleural origin is especially very uncommon.

PATIENT CONCERNS

An 85-year-old man presenting with progressive dyspnea for more than 7 days.

DIAGNOSES

Computed tomography scan of the chest showed massive pleural effusion and diffuse nodular thickening of the pleura on the right chest. Sonography-guided needle biopsy of the pleural mass was performed and histologic and immunohistochemical findings revealed SCC. Since no parenchymal lung lesion was observed, the patient was finally diagnosed with SCC of the pleura (SCCP).

INTERVENTIONS

Due to the patient's old age and poor performance status, chemotherapy was not performed and only drainage of pleural effusion was conducted for symptom relief.

OUTCOMES

Dyspnea improved after pleural effusion drainage. The patient was discharged and transferred to a local medical center for hospice care.

LESSONS

Although primary SCCP is extremely rare, SCCP should also be considered as well as mesothelioma in case of presence of a pleural-based mass with massive pleural effusion.

A case report of an expensive yet necessary thoracentesis: Expanding the boundaries of endoscopic ultrasound transbronchial needle aspiration

RATIONALE

Endobronchial ultrasound has revolutionized the field of bronchoscopy and has become one of the most important tools for the diagnosis of intrathoracic lymphadenopathy and para-bronchial structures. The reach of this technique has not been limited to these structures and pleural lesions have been at times accessible. To our knowledge, pleural fluid collections have not been accessed with endobronchial ultrasound (EBUS).

PATIENT CONCERNS

52-year-old women with dyspnea, fever and a new loculated pleural effusion that was suspected to be the source of the fever but was not accessible through traditional thoracentesis.

DIAGNOSIS

Malignant pleural effusion.

INTERVENTIONS

Sampling and drainage of the loculated pleural fluid collection using EBUS scope introduced via the esophagus.

OUTCOMES

Infection excluded. Resolution of fever and improved dyspnea after drainage of effusion.

LESSONS

The convex curvilinear ultrasound bronchoscope allows unprecedented access to thoracic structures. The reach is not limited to mediastinal lymph nodes and parenchymal masses adjacent to the airways, and pleural space and pleural fluid are at times accessible, particularly when one considers the esophageal approach.

The Safety of Ultrasound-Guided Thoracentesis in Patients on Novel Oral Anticoagulants and Clopidogrel: A Single-Center Experience

OBJECTIVE

To assess the risk of hemorrhagic complications in patients taking novel oral anticoagulants (NOACs) and/or clopidogrel who underwent an ultrasound-guided thoracentesis.

PATIENTS AND METHODS

A retrospective analysis was performed of ultrasound-guided thoracenteses completed at an academic institution between January 1, 2016, and November 14, 2017. All patients who underwent a thoracentesis while actively receiving treatment with an NOAC and/or clopidogrel were included in the study. Primary endpoints are any significant post-procedure bleeding complication; defined as a hemoglobin decrease of greater than 2 g/dL in 48 hours, hemothorax, chest wall hematoma, and bleeding requiring transfusion, surgery, or chest tube placement.

RESULTS

A total of 115 thoracenteses were performed in 103 patients actively taking an NOAC (n=43) and/or clopidogrel (n=69). All patients used either the NOAC or clopidogrel within 24 hours before the procedure and continued using it daily thereafter. There were no bleeding complications.

CONCLUSION

The overall risk of significant hemorrhage in patients taking an NOAC and/or clopidogrel while undergoing ultrasound-guided thoracentesis is very low. Albeit the total number of procedures reviewed may be insufficient to prove definitive safety, it is sufficient to provide a measure of relative risk when assessing benefits of thoracentesis in these patients.

Diagnostic value of polymerase chain reaction/acid-fast bacilli in conjunction with computed tomography-guided pleural biopsy in tuberculous pleurisy: A diagnostic accuracy study

Patients with tuberculous pleurisy often remain undiagnosed even after blind thoracentesis and closed pleural biopsy (PB). In this study, we assessed the value of computed tomography (CT)-guided core needle biopsy of pleural lesion and evaluated the diagnostic accuracy of polymerase chain reaction (PCR)/staining for acid-fast bacilli (AFB) in suspicious tuberculous pleurisy undiagnosed in blind thoracentesis.Patients with exudative pleural effusion (PE) without specific etiology after blind thoracentesis and closed PB were enrolled in this study. PB specimens were obtained through CT-guided core needle biopsy of pleural lesion, then underwent PCR, AFB, histopathological examination, and some routine tests. Diagnostic values were evaluated through sensitivity, specificity, negative predictive value, positive predictive value, and accuracy.A total of 261 participants (TB group: 241, non-TB group: 20) were recruited. In this cohort, the sensitivity, specificity, and accuracy were 56.0%, 95.0%, and 59.0%, respectively for PCR, whereas 57.3%, 95.0%, and 60.2%, respectively for AFB. Their parallel test achieved an improved sensitivity (76.8%) and accuracy (77.8%), with a slight decrease in specificity (90.0%). In histopathological examination, granuloma was the most common finding in TB group (88.4%, 213/241), but also observed in non-TB group (10.0%, 2/20). In addition, pleural lymphocyte percentage in TB group was significantly higher than that of non-TB group (92% vs 61%, respectively; P = .003). However, no significant differences were found for other biomarkers.CT-guided core needle PB is essential for patients with exudative PE but undiagnosed after blind thoracentesis. Combining with PCR and AFB, it strongly improves the diagnosis of tuberculous pleurisy.

Effect of closed vacuum aspiration technique on lung collapse time in thoracoscopic anatomical segmentectomy

To investigate the effect of lung expansion and collapse method combined with closed vacuum aspiration technique on lung collapse time, reduce the waiting time of surgery.Forty patients with pulmonary peripheral nodules under thoracoscopic anatomical segmentectomy were divided into 20 cases of natural collapse group and 20 cases of modified collapse group. The natural collapse group used the traditional natural collapse method, and the modified collapse group used a lung expansion and collapse method combined with closed vacuum aspiration technique to record the lung collapse time and compare them.Thoracoscopic anatomical segmentectomy was successfully performed in both groups. The lung collapse time in the natural collapse group and the modified collapse group was 17.08 ± 1.35, 8.90 ± 0.39, respectively, P < .05.The lung expansion and collapse method combined with closed vacuum aspiration technique can reduced the waiting time of lung collapse during thoracoscopic anatomical segmentectomy, and can processed the inter-segment boundary better, thereby reduced the waiting time of surgery.

Needle aspiration versus intercostal tube drainage for pneumothorax in the newborn

BACKGROUND

Pneumothorax occurs more frequently in the neonatal period than at any other time of life and is associated with increased mortality and morbidity. It can be treated with either aspiration with a syringe (using a needle or an angiocatheter) or a chest tube inserted in the anterior pleural space and then connected to a Heimlich valve or an underwater seal with continuous suction.

OBJECTIVES

To compare the efficacy and safety of needle aspiration (either with immediate removal of the needle or with the needle left in situ) to intercostal tube drainage in the management of neonatal pneumothorax (PTX).

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 4 June 2018), Embase (1980 to 4 June 2018), and CINAHL (1982 to 4 June 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials and cluster trials comparing needle aspiration (either with the needle or angiocatheter left in situ or removed immediately after aspiration) to intercostal tube drainage in newborn infants with pneumothorax.

DATA COLLECTION AND ANALYSIS

For each of the included trials, two authors independently extracted data (e.g. number of participants, birth weight, gestational age, kind of needle and chest tube, choice of intercostal space, pressure and device for drainage) and assessed the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). The primary outcomes considered in this review are mortality during the neonatal period and during hospitalisation.We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

Two randomised controlled trials (142 infants) met the inclusion criteria of this review. We found no differences in the rates of mortality when the needle was removed immediately after aspiration (risk ratio (RR) 3.92, 95% confidence interval (CI) 0.88 to 17.58; participants = 70; studies = 1) or left in situ (RR 1.50, 95% CI 0.27 to 8.45; participants = 72; studies = 1) or complications related to the procedure. With immediate removal of the needle following aspiration, 30% of the newborns did not require the placement of an intercostal tube drainage. None of the 36 newborns treated with needle aspiration with the angiocatheter left in situ required the placement of an intercostal tube drainage. Overall, the quality of the evidence supporting this finding is very low.

AUTHORS' CONCLUSIONS

There is insufficient evidence to establish the efficacy and safety of needle aspiration and intercostal tube drainage in the management of neonatal pneumothorax. The two included trials showed no differences in mortality; however the information size is low. Needle aspiration reduces the need for intercostal tube drainage placement. Limited or no evidence is available on other clinically relevant outcomes.

Pleural amyloidosis with recurrent pleural effusion and pulmonary embolism: A case report

RATIONAL

Clinical and radiologic manifestations of pleural amyloidosis are non-specific. And it can easily be missed or misdiagnosed. Meanwhile, few studies document amyloidosis presenting with pulmonary infarcts at the same time. Hereby, we report a case of immunoglobulin light chain amyloidosis (AL) pleural amyloidosis with pulmonary embolism rarely reported.

PATIENT CONCERNS

A 66-year-old male patient who suffered recurrent pleural effusion for more than 6 months and coughed for 2 months was admitted to hospital for clear diagnosis and treatment. He was previously engaged in a job which exposed him to dust and talcum powder for a long time. He underwent right thoracentesis and anti-infective treatment before admission. The patient's cough and shortness of breath were slightly relieved. He still experienced pleural effusion and had symptoms of cough and shortness of breath.

DIAGNOSIS

Chest X-ray demonstrated bilateral pleural effusion. Chest computed tomography (CT) angiography demonstrated left lower pulmonary embolism. The thorascopy showed hyperaemia and black tissue of the parietal pleura, which were biopsied. The pathological diagnosis was amyloidosis. The final diagnosis of this patient was AL pleural amyloidosis and left lower pulmonary embolism.

INTERVENTION

During the hospitalization, the patient underwent thoracentesis several times without any conclusive diagnosis. After the diagnosis of pleural amyloidosis, the patient was repeatedly advised to undergo bone marrow biopsy and pleurodesis which the patient refused. For pulmonary embolism, Nadroparin calcium combined Warfarin were administered as anticoagulative therapy.

OUTCOMES

The pulmonary embolism resolved 13 days after the anticoagulant therapy. The patient refused treatment for pleural effusion and requested for discharge. At the time of discharge, shortness of breath was relieved, and the pleural effusion had decreased. The patient was lost to follow-up.

LESSONS

Amyloidosis is a rare disease which can be ignored by many clinicians. It needs to be diagnosed promptly since the prognosis of amyloidosis is poor. Clinicians must improve relevant understandings of this kind of disease so as not to delay the diagnosis and treatment. We must be alert to the occurrence of embolic disease among amyloidosis patients. Last but not least, we should also think of the possibility of amyloidosis in patients with pulmonary embolism and recurrent pleural effusion.

Recurrent, late-onset pleural effusions in elderly patients receiving pacemaker therapy

Late-onset pacemaker-related pleural effusions (PEs) are rare and are often misdiagnosed with other entities. Our study aimed to detail the clinical features and management of PEs long after pacemaker insertion.We conducted a review of 6 consecutive elderly patients with PEs, who had undergone a new pacemaker insertion from September 2014 to January 2017. Also, the clinical characteristics and therapeutic courses of PEs were summarized.Two cases involved fluids after the first implantations, with pacing durations of 3 and 7 months. Two other cases developed PEs 3 or 4 months after the first replacement, with pacing durations of 6 and 11 years. Another 2 cases developed PEs 3 or 5 months following the second replacement, with total pacing durations of 16 and 18 years, respectively. The average interval was 4.17 months for the 6 cases from the time of the new pacemaker insertion to the occurrence of PEs. During the course, they had to be hospitalized repeatedly for thoracenteses because conventional treatments had only short-term effects. After the pacing settings were adjusted, PEs in all cases disappeared gradually. No patients were readmitted for PEs during the median follow-up period of 13 months.For elderly patients following implantation of a new pacemaker, PEs should be considered due to improper pacing settings, and corresponding adjustments to the device should be made.

Recommendations on the Use of Ultrasound Guidance for Adult Thoracentesis: A Position Statement of the Society of Hospital Medicine

Executive Summary: 1) We recommend that ultrasound should be used to guide thoracentesis to reduce the risk of complications, the most common being pneumothorax. 2) We recommend that ultrasound guidance should be used to increase the success rate of thoracentesis. 3) We recommend that ultrasound-guided thoracentesis should be performed or closely supervised by experienced operators. 4) We suggest that ultrasound guidance be used to reduce the risk of complications from thoracentesis in mechanically ventilated patients. 5) We recommend that ultrasound should be used to identify the chest wall, pleura, diaphragm, lung, and subdiaphragmatic organs throughout the respiratory cycle before selecting a needle insertion site. 6) We recommend that ultrasound should be used to detect the presence or absence of an effusion and approximate the volume of pleural fluid to guide clinical decision-making. 7) We recommend that ultrasound should be used to detect complex sonographic features, such as septations, to guide clinical decision-making regarding the timing and method of pleural drainage. 8) We suggest that ultrasound be used to measure the depth from the skin surface to the parietal pleura to help select an appropriate length needle and determine the maximum needle insertion depth. 9) We suggest that ultrasound be used to evaluate normal lung sliding pre- and postprocedure to rule out pneumothorax. 10) We suggest avoiding delay or interval change in patient position from the time of marking the needle insertion site to performing the thoracentesis. 11) We recommend against performing routine postprocedure chest radiographs in patients who have undergone thoracentesis successfully with ultrasound guidance and are asymptomatic with normal lung sliding postprocedure. 12) We recommend that novices who use ultrasound guidance for thoracentesis should receive focused training in lung and pleural ultrasonography and hands-on practice in procedural technique. 13) We suggest that novices undergo simulation-based training prior to performing ultrasound-guided thoracentesis on patients. 14) Learning curves for novices to become competent in lung ultrasound and ultrasound-guided thoracentesis are not completely understood, and we recommend that training should be tailored to the skill acquisition of the learner and the resources of the institution.

Empyema caused by a colopleural fistula: A case report

RATINALE

Empyema is a condition in which pus gathers in the area between the lungs and the inner surface of the chest wall. An empyema caused by colo-pleural fistula is a rare but potentially life-threatening condition.

PATIENT CONCERNS

We describe a case of 42-year-old man was brought to our Emergency Department for chest pain with dyspnea and fever.

DIAGNOSES

The final diagnoses are empyema caused by colo-pleural fistula and colon cancer.

INTERVENTIONS

The patient underwent laparotomy surgery, during which a tumor was found in the splenic flexure of the descending colon. The tumor penetrated the colonic serosa and invaded the left side of the diaphragm. A left hemicolectomy was performed.

OUTCOMES

After the operation, the patient recovered smoothly and was discharged on postoperative day 14. It's been over 3 years now, CT and colonoscopy assessments show no recurrence or metastasis.

LESSONS

This case serves as a reminder to test for pathogens in patients with an unexplained empyema. If normal intestinal bacteria are detected, the empyema may be derived from intestinal disease. In addition, an abdominal examination should be performed in patients with an empyema of unknown origin.

Safe and Effective Bedside Thoracentesis: A Review of the Evidence for Practicing Clinicians

BACKGROUND

Physicians often care for patients with pleural effusion, a condition that requires thoracentesis for evaluation and treatment. We aim to identify the most recent advances related to safe and effective performance of thoracentesis.

METHODS

We performed a narrative review with a systematic search of the literature. Two authors independently reviewed search results and selected studies based on relevance to thoracentesis; disagreements were resolved by consensus. Articles were categorized as those related to the pre-, intra- and postprocedural aspects of thoracentesis.

RESULTS

Sixty relevant studies were identified and included. Pre-procedural topics included methods for physician training and maintenance of skills, such as simulation with direct observation. Additionally, pre-procedural topics included the finding that moderate coagulopathies (international normalized ratio less than 3 or a platelet count greater than 25,000/μL) and mechanical ventilation did not increase risk of postprocedural complications. Intraprocedurally, ultrasound use was associated with lower risk of pneumothorax, while pleural manometry can identify a nonexpanding lung and may help reduce risk of re-expansion pulmonary edema. Postprocedurally, studies indicate that routine chest X-ray is unwarranted, because bedside ultrasound can identify pneumothorax.

CONCLUSIONS

While the performance of thoracentesis is not without risk, clinicians can incorporate recent advances into practice to mitigate patient harm and improve effectiveness. Journal of Hospital Medicine 2017;12:266-276.

Analysis of clinical and radiological features of tuberculosis associated pneumothorax

AIM

To investigate the demographic and clinico-radiological characteristic of patients of tuberculosis presented with pneumothorax in relation to the patients of active pulmonary tuberculosis.

MATERIAL AND METHODS

The retrospective study was conducted between January 2013 to June 2014 and records of 78 patients of pulmonary tuberculosis with pneumothorax (TP) and 156 patients of pulmonary tuberculosis without pneumothorax (NPT) were analyzed. Demographic, etiologic, clinical, radiographic, and outcome data were collected.

RESULTS

The mean age of tuberculous pneumothorax patients was 38.0±14.3 years and that of non-pneumothorax was 39.5±12.3 years. Most common presenting clinical feature was cough (76.9%) followed by dyspnoea (74.4%), chest pain (64.0%) and fever (56.4%) in TP patients. Chest radiograph showed cavity in 38 (48.7%) TP patients followed by consolidation in 32 (41.0%) patients and infiltration in 33 (42.3%) patients. All the TP patients had undergone underwater seal intercostal tube drainage procedure for the management of pneumothorax. The mean duration between chest drain insertion and removal was 17.14±6.37 days. Twenty-five (32.1%) of the cases developed chest tube drainage related complications.

CONCLUSION

Patients of tuberculous pneumothorax required prolonged period of chest tube drainage and usually showed good response to the treatment.

Povidone Iodine Pleurodesis for Refractory Congenital Chylothorax: A Review of Literature

BACKGROUND

Povidone iodine (PVI) pleurodesis is commonly used in adult. However, this procedure is still nonconsensual in newborns.

AIMS

This article aimed to report a new case of refractory congenital chylothorax (CCT) managed with PVI pleurodesis with a review of previousreported cases.

METHODS

a systematic review of similar cases published in PubMed. Clinical patterns, therapeutic modalities and outcome variables werereported.

RESULT

In a full term neonate presenting refractory CCT, PVI pleurodesis was performed at day 16 of life by one intrapleural instillation of PVI4% with rapid success and no side effects. Renal function and thyroid tests stilled normal before and after instillation. The analysis of 18 casesreported in Medeline and our observation provided the following data: this procedure was successful without side effects in 11/19 cases. Severeside effects were reported in four patients with high risks before procedure.

CONCLUSION

PVI pleurodesis seems to be effective and inoffensive in the management of refractory CCT. It may be a good alternative tosurgery. Nevertheless, randomized studies on large neonatal population are required to precise: the risks and benefits of this procedure, thetiming and the modalities of its realization (duration of intervention, dilution and dosage of PVI) according to the patient`s field (gestational age,weight and associated morbidity).

The effect of simulation-based mastery learning on thoracentesis referral patterns

Internal medicine (IM) residents and hospitalist physicians commonly perform thoracenteses. National data show that thoracenteses are also frequently referred to other services such as interventional radiology (IR), increasing healthcare costs. Simulation-based mastery learning (SBML) is an effective method to boost physicians' procedural skills and self-confidence. This study aimed to (1) assess the effect of SBML on IM residents' simulated thoracentesis skills and (2) compare thoracentesis referral patterns, self-confidence, and reasons for referral between traditionally trained residents (non-SBML-trained), SBML-trained residents, and hospitalist physicians. A random sample of 112 IM residents at an academic medical center completed thoracentesis SBML from December 2012 to May 2015. We surveyed physicians caring for hospitalized patients with thoracenteses during the same time period and compared referral patterns, self-confidence, and reasons for referral. SBML-trained resident thoracentesis skills improved from a median of 57.6% (interquartile range [IQR] 43.3-76.9) at pretest to 96.2% (IQR 96.2-100.0) at post-test (P < 0.001). Surveys demonstrated that traditionally trained residents were more likely to refer to IR and cited lower confidence as reasons. SBML-trained residents were more likely to perform bedside thoracenteses. Hospitalist physicians were most likely to refer to pulmonary medicine and cited lack of time to perform the procedure as the main reason. SBML-trained residents were most confident about their thoracentesis skills, despite hospitalist physicians having more experience. This study identifies confidence and time as reasons physicians refer thoracenteses rather than perform them at the bedside. Thoracentesis SBML boosts skills and promotes bedside procedures that are safe and less expensive than referrals. Journal of Hospital Medicine 2016;11:792-795. © 2016 Society of Hospital Medicine.

Recent advances in endobronchial ultrasound-guided transbronchial needle aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive modality for sampling of mediastinal and hilar lymph nodes as well as pulmonary lesions adjacent to the airway. Guidelines for staging of lung cancer suggest that EBUS-TBNA should be considered the best first test of nodal staging for radiologically abnormal lymph nodes that are accessible by this approach. The application of EBUS-TBNA in pulmonary medicine and thoracic oncology is expanding with its role in the diagnosis of sarcoidosis, lymphoma, and tuberculosis. Especially for patients with early-stage sarcoidosis with adenopathy and minimal changes in the lung parenchyma, EBUS-TBNA has a significantly higher diagnostic yield compared to the conventional bronchoscopic modalities. Multidirectional analysis of samples obtained by EBUS-TBNA has allowed assessment of lymphoma and molecular analysis in lung cancer. Histological evaluation with immunohistochemistry, flow cytometry, fluorescence in situ hybridization, and chromosome analysis can be performed if good-quality samples can be obtained. Molecular analyses such as identification of epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) fusion gene detection now are being performed routinely with good sampling. One of the advantages of EBUS-TBNA is the ability to perform repeat procedures in a minimally invasive way. Restaging of the mediastinum after induction therapy can be done safely and with ease compared to repeat surgical procedures. With improvement in molecular analysis technology, comprehensive gene expression analysis will become important in the management of patients with lung cancer. Further advances in EBUS technology and needles for tissue sampling likely will help bronchoscopists to acquire ideal tissue.

Symptomatic Unilateral Pleural Effusion Secondary due to Ovarian Hyperstimulation Syndrome

Isolated pleural effusion is a rare presentation of ovarian hyperstimulation syndrome following ovulation induction therapy. We hereby report the case of a 24-year-old female who presented with unilateral moderate pleural effusion following ovulation induction therapy. Therapeutic thoracentesis was performed to relieve the breathlessness in this case.

Needle aspiration versus intercostal tube drainage for pneumothorax in the newborn

BACKGROUND

Pneumothorax occurs more frequently in the neonatal period than at any other time of life and is associated with increased mortality and morbidity. It may be treated with either needle aspiration or insertion of a chest tube. The former consists of aspiration of air with a syringe through a needle or an angiocatheter, usually through the second or third intercostal space in the midclavicular line. The chest tube is usually placed in the anterior pleural space passing through the sixth intercostal space into the pleural opening, turned anteriorly and directed to the location of the pneumothorax, and then connected to a Heimlich valve or an underwater seal with continuous suction.

OBJECTIVES

To compare the efficacy and safety of needle aspiration and intercostal tube drainage in the management of neonatal pneumothorax.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 11), MEDLINE via PubMed (1966 to 30 November 2015), EMBASE (1980 to 30 November 2015), and CINAHL (1982 to 30 November 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials and cluster trials comparing needle aspiration (either with the needle or angiocatheter left in situ or removed immediately after aspiration) to intercostal tube drainage in newborn infants with pneumothorax.

DATA COLLECTION AND ANALYSIS

For each of the included trial, two authors independently extracted data (e.g. number of participants, birth weight, gestational age, kind of needle and chest tube, choice of intercostal space, pressure and device for drainage) and assessed the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). The primary outcomes considered in this review are mortality during the neonatal period and during hospitalisation.

MAIN RESULTS

One randomised controlled trial (72 infants) met the inclusion criteria of this review. We found no differences in the rates of mortality (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.27 to 8.45) or complications related to the procedure. After needle aspiration, the angiocatheter was left in situ (mean 27.1 hours) and not removed immediately after the aspiration. The angiocatheter was in place for a shorter duration than the intercostal tube (mean difference (MD) -11.20 hours, 95% CI -15.51 to -6.89). None of the 36 newborns treated with needle aspiration with the angiocatheter left in situ required the placement of an intercostal tube drainage. Overall, the quality of the evidence supporting this finding is low.

AUTHORS' CONCLUSIONS

At present there is insufficient evidence to determine the efficacy and safety of needle aspiration versus intercostal tube drainage in the management of neonatal pneumothorax. Randomised controlled trials comparing the two techniques are warranted.

[Ultrasonography-guided procedures of the doctor on call]

The use of ultrasonography in guiding minor procedures reduces the possibility of procedural complications. Fluid is easy to identify, enabling the utilization of ultrasonography even with a lesser experience. In skilled hands, drainage of ascitic fluid, pleurocentesis and insertion of a suprapubic catheter are safe procedures. Careful planning of the procedure in advance will contribute to safety. Before undertaking the procedure, one should confirm the patient's coagulation status and appropriate interruption of possible antithrombotic medication. The injection site is chosen on anatomical grounds, avoiding any blood vessels. The ultrasound view is adjusted optimally so that the route of injection can be seen as clearly as possible on the screen.

Noonan Syndrome Complicated by Primary Pulmonary Lymphangiectasia

Noonan syndrome is a genetic disorder that has several features common to other conditions, making diagnosis a challenge. This column summarizes the case of a neonate with an atypical presentation of Noonan syndrome involving a fatal type of lymphangiectasia resulting in persistent pleural effusions. Radiographic features of this condition are presented along with the complexities of diagnosis and treatment.