A supplementary technique for localized pneumothorax requiring tube thoracostomy: scopy

Management of pediatric occult pneumothorax in blunt trauma: a subgroup analysis of the American Association for the Surgery of Trauma multicenter prospective observational study

Computed tomography-detected hemothorax after blunt chest trauma: Does everyone need an intervention? A retrospective analysis.

Chest trauma in childhood is relatively uncommon in clinical practice, and has been the subject of few reports in the literature. This study was undertaken to examine our experience in dealing with chest trauma in children. This was a retrospective study of 74 children who sustained chest trauma, and were referred to King Fahad Hospital in Medina over a two-year period. The age, cause of injury, severity of injury, associated extrathoracic injuries, treatment and outcome were analyzed. The median age of the patients was nine years. Fifty-nine of them (80%) sustained blunt trauma, and 15 (20%) were victims of penetrating injuries. Road traffic accident was the cause of chest trauma in 62% of the children, gun shot wounds were seen in five, and stab wounds in 10 children. Head injury was the most common injury associated with thoracic trauma, and was seen in 14 patients (19%), and associated intraabdominal injuries were seen in nine patients. Chest x-ray of the blunt trauma patients revealed fractured ribs in 24 children, pneumothorax in six, hemothorax in four, hemopneumothorax in three, and pulmonary contusions in 22 patients. Fifty-one percent of children were managed conservatively, 37% required tube thoracostomy, 8% were mechanically ventilated, and 4% underwent thoracotomy. The prevalence of chest trauma in children due to road traffic accidents is high in Saudi Arabia. Head injury is thought to be the most common associated extrathoracic injuries, however, most of these patients can be managed conservatively.

Tube thoracostomy (TT) is required in the treatment of many blunt and penetrating injuries of the chest. In addition to complications from the injuries, TT may contribute to morbidity by introducing microorganisms into the pleural space or by incomplete lung expansion and evacuation of pleural blood. We have attempted to assess the impact of TT following penetrating and blunt thoracic trauma by examining a consecutive series of 216 patients seen at two urban trauma centers with such injuries who required TT over a 30-month period. Ninety-four patients suffered blunt chest trauma; 122 patients were victims of penetrating wounds. Patients with blunt injuries had longer ventilator requirements (12.6 +/- 14 days vs. 3.7 +/- 7.1 days, p = 0.003), longer intensive care stays (12.2 +/- 12.5 days vs. 4.1 +/- 7.5 days, p = 0.001), and longer periods of TT, (6.5 +/- 4.9 days vs. 5.2 +/- 4.5 days, p = 0.018). Empyema occurred in six patients (3%). Residual hemothorax was found in 39 patients (18%), seven of whom required decortication. Recurrent pneumothorax developed in 51 patients (24%) and ten required repeat TT. Complications occurred in 78 patients (36%). Patients with blunt trauma experienced more complications (44%) than those with penetrating wounds (30%) (p = 0.04). However, only seven of 13 patients developing empyema or requiring decortication had blunt trauma. Despite longer requirements for mechanical ventilation, intensive care, and intubation, victims of blunt trauma seemed to have effective drainage of their pleural space by TT without increased risk of infectious complications.

Air Transport of Patients with Pneumothorax: Is Tube Thoracostomy Required Before Flight?

In this report, we describe a new sonographic (US) technique that can assist in the aspiration of a loculated pneumothorax. Patients may develop loculated pneumothorax as a result of such conditions as pleural malignancy or pleural infection or after undergoing thoracic surgery. Often the loculated pneumothorax is outside of safe areas, and chest tubes need to be placed near vital structures. This report presents the cases of three patients with iatrogenic loculated pneumothorax that required aspiration. We used US to assist in the placement of chest tubes, and we describe our technique of US-assisted aspiration of loculated pneumothorax. The procedure is a new approach to a common problem in chest medicine that may increase the safety of treatment. © 2015 Wiley Periodicals, Inc. J Clin Ultrasound 44:326-330, 2016.

Chest injury is a common problem in patients sustaining blunt or penetrating trauma.1 Thoracic wounds account for 20-25% of all trauma deaths. Only 10-15% of all chest wounds require tube thoracostomy, whereas the remaining 85% can be managed with a closed tube thoracostomy.2 A major morbidity associated with this therapeutic device is empyema. The role of prophylactic antibiotics in reducing the incidence of this complication is controversial. Multiple factors contribute to the development of posttraumatic empyema. These factors include the conditions under which the tube is inserted (emergent or urgent), the mechanism of injury, retained hemothorax and ventilator care.3-8 The primary goal of prophylactic antibiotic use in injured patients requiring tube thoracostomy is to reduce the incidence of empyema and its associated morbidity. The primary benefit must be significant because of the risk of the emergence of resistant organisms with excessive use of antimicrobials. In addition, cost is a major concern in the current health care market. The above-mentioned concerns were the reasons for performing this study. Patients and methods This study is a randomized controlled trial. It took place over a 2-year period from June 2005 to June 2007. Patients aged 8-72 years with traumatic hemopneumothorax following blunt chest trauma and receiving chest tube placement were enrolled for the trial. Patients were excluded if they had penetrating chest trauma, needed to receive different antibiotics because of other injuries or had known immune-compromising disorders. The patients were classified as group-A and group-B randomly, with 54 cases out of 104 being assigned to group-A. The remainder (50 cases) was assigned to group-B. Since there are currently no clear-cut recommendations regarding antibiotic use in patients requiring tube thoracostomy to treat chest injury, there was no ethical deviation in this study. Group-A received 2gr of Cefazolin for the first 24 hours and group-B received a placebo. Patients were then followed daily for signs of empyema or pneumonia. Patients then received a telephone follow-up at 3 months after discharge evaluating for delayed evidence of empyema or pneumonia. In this study empyema is defined as a positive pleural culture or purulence within the thoracic space in conjunction with elevated white blood cell count and /or fever. Also, pneumonia was defined as evolving infiltrate on chest radiograph 24 hours after inserting the chest tube with either purulent sputum or a positive sputum culture. Our sample consisted of 75% males and 25% females with an average age of 39.6 years. The indication for tube placement was pneumothorax in 74 (69.2%), hemothorax in 20 (19.2%) and hemopneumothorax in 12 (11.5%). Totally 112 chest tubes were inserted. Eight of these patients received bilateral tubes. The average duration of tube placement was 6.8 days. Six patients developed pneumonia, 2 in group-A, 4 in group-B (p = 0.3). One patient from group-B developed empyema (p=0.48). Overall, this study revealed that prophylactic antibiotics did not significantly reduce the incidence of empyema or pneumonia in patients with blunt chest trauma. The use of prophylactic antibiotics for the prevention of empyema and pneumonia after tube thoracostomy remains a controversial issue in the trauma literature. While a number of studies show favorable effects, several reports have shown no benefit. 6-8 In our study the incidence of empyema was very low. Having prescribed prophylactic antibiotics to a large numbers of patients, we managed to prevent just a single empyema. We concluded that prophylactic antibiotic administration did not significantly reduce the incidence of empyema or pneumonia in these patients. Therefore, considering the emergence of resistant organisms and the cost and benefit, it seems that prophylactic antibiotics should not be administered in the management of chest tubes for blunt chest trauma; however, larger and more comprehensive studies should be performed to confirm this.

Candidates for stem cell transplantation may occasionally suffer from massive pleural effusions related to their disease and require tube thoracostomy. The additional risk of this procedure during allogeneic transplantation procedure is not known. Four high-risk patients transplanted in our institution during a 2-yr period had chest drainage by tube thoracostomy. The characteristics of the fluid, the clinical course, and the outcome were assessed. A total of nine chest drains were inserted (range 1-5). No bleeding complications related to the procedure were noted. None of the patients developed any clinical signs of local infection at the tube insertion site or within the pleural fluid. All cultures taken from the drained fluid or from the insertion wound were negative. Tube thoracostomy in itself does not seem to pose additional risks in the transplant procedure, despite all patients in this series being considered to be at high-risk for complications.

Empyema remains a distressing complication after thoracic injury. To identify high-risk factors associated with the development of empyema. Retrospective cohort review. University hospital, level I trauma center. Trauma patients who required tube thoracostomy (TT) between January 1, 1991, and November 31, 1993 (n = 584). Data (demographic characteristics, injuries, chest x-ray film reports, and setting of TT) were assessed using a stepwise logistic regression analysis to identify risk factors associated with the development of post-traumatic empyema. Empyema that required decortication developed in 25 patients (4%). Factors predictive of development of empyema were retained hemothorax (odds ratio, 12.5; 95% confidence interval, 0.96-163), pulmonary contusion (odds ratio, 6.3; 95% confidence interval, 1.53-25.8), and multiple chest tube placement (odds ratio, 2.5; 95% confidence interval, 1.91-3.28); factors not predictive of empyema were severity of injury, mechanism of injury, setting in which TT was performed, number of days chest tubes were in place, and antibiotic drugs at the time of TT. The extent of pulmonary injury (pulmonary contusion) is an important predictor of empyema development. Previously implicated factors such as setting in which a TT was performed and mechanism of injury did not correlate with the development of posttraumatic empyema. Based on the results of our study, we recommend early drainage of the pleural space with video-assisted thoracoscopic techniques in patients at risk of empyema, which may spare them the morbidity of a thoracotomy.

BackgroundMalignant 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.MethodsA 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.ResultsFrom 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.ConclusionsThe 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 focused assessment with sonography for trauma (FAST) examination has become the standard of care for rapid evaluation of trauma patients. Extended FAST (eFAST) is the use of ultrasonography for the detection of pneumothorax (PTX). The exact sensitivity and specificity of eFAST detecting traumatic PTX during practical "real-life" application is yet to be investigated. This is a retrospective review of all trauma patients with a diagnosis of PTX, who were treated at a large level 1 urban trauma center from March 2013 through July 2014. Charts were reviewed for results of imaging, which included eFAST, chest X-ray, and CT scan. The requirement of tube thoracostomy and mechanism of injury were also analyzed. A total of 369 patients with a diagnosis of PTX were identified. A total of 69 patients were excluded, as eFAST was either not performed or not documented, leaving 300 patients identified with PTX. A total of 113 patients had clinically significant PTX (37.6%), requiring immediate tube thoracostomy placement. eFAST yielded a positive diagnosis of PTX in 19 patients (16.8%), and all were clinically significant, requiring tube thoracostomy. Chest X-ray detected clinically significant PTX in 105 patients (92.9%). The literature on the utility of eFAST for PTX in trauma is variable. Our data show that although specific for clinically significant traumatic PTX, it has poor sensitivity when performed by clinicians with variable levels of ultrasound training. We conclude that CT is still the gold standard in detecting PTX, and clinicians performing eFAST should have adequate training.

This study aimed to develop and assess the performance of an artificial intelligence(AI)-driven decision support system, XRAInet, in accurately identifying pediatric patients with pleural effusion or pneumothorax and determining whether tube thoracostomy intervention is warranted. In this diagnostic accuracy study, we retrospectively analyzed a data set containing 510 X-ray images from 170 pediatric patients admitted between 2005 and 2022. Patients were categorized into two groups: Tube (requiring tube thoracostomy) and Conservative (managed conservatively). XRAInet, a deep learning-based algorithm, was trained using this data set. We evaluated its performance using various metrics, including mean Average Precision (mAP), recall, precision, and F1 score. XRAInet, achieved a mAP score of 0.918. This result underscores its ability to accurately identify and localize regions necessitating tube thoracostomy for pediatric patients with pneumothorax and pleural effusion. In an independent testing data set, the model exhibited a sensitivity of 64.00% and specificity of 96.15%. In conclusion, XRAInet presents a promising solution for improving the detection and decision-making process for cases of pneumothorax and pleural effusion in pediatric patients using X-ray images. These findings contribute to the expanding field of AI-driven medical imaging, with potential applications for enhancing patient outcomes. Future research endeavors should explore hybrid models, enhance interpretability, address data quality issues, and align with regulatory requirements to ensure the safe and effective deployment of XRAInet in healthcare settings.

A 72-year-old man with a right middle lobe lung adenocarcinoma underwent lobectomy with removal of tube thoracostomy 3 days after the thoracic surgery. He presented approximately 3 weeks after surgery...

Radiofrequency Ablation in the Lung Complicated by Positive Airway Pressure Ventilation

Management of 240 cases of penetrating thoracic injuries