Bilateral Chest Tubes Research Articles

Occult Tracheobronchial Injury

Tracheobronchial disruption is a rare, life-threatening injury associated with severe blunt chest trauma. Most injuries occur within 2.5 cm of the main carina and more often involve the right main bronchus. We report a case of occult tracheobronchial injury located in a left subsegmental bronchus discovered with flexible bronchoscopy in a 21-year-old man who sustained chest trauma after a motorcycle accident. He presented with a pneumomediastinum, right pneumothorax, and left hemothorax requiring thoracotomy to achieve hemostasis. Several hours postoperatively he developed refractory hypoxemia despite insertion of bilateral chest tubes and increased positive pressure ventilation. Flexible bronchoscopy at the bedside revealed the aforementioned bronchial disruption. A review of the literature on tracheobronchial injury and role of flexible bronchoscopy is presented.

Tracheobronchial injuries

A 27-year-old man, formerly in good health, arrived at the local trauma center after a high-speed rollover motor vehicle crash. He was in frank shock, with bilateral tension pneumothoraces. The team intubated him immediately and placed bilateral chest tubes. A computed tomography scan of the head showed severe traumatic brain injury with diffuse axonal injury and intraventricular bleeding. Additional injuries included bilateral full-thickness burns to his lower extremities, multiple facial fractures, multiple rib fractures, and pulmonary contusion.

Images in anesthesia: Bilateral pneumothorax following tracheal extubation

gency.1 Iatrogenic pneumothorax is more common than all forms of spontaneous pneumothorax.2 – 5 A 55-yr-old, 101 kg, male underwent cardiac surgery under general anesthesia. Examination of the heart and lungs showed no abnormality and the patient’s past medical history did not indicate any respiratory disease. The preoperative chest radiograph was normal. Arterial blood pressure, heart rate, and arterial oxygen saturation (SpO2) were stable during the operation. Because of hemodynamic instability extubation was possible only six days postoperatively. Soon after extubation, the patient developed cyanosis and SpO2 declined to 90%. Chest radiography revealed bilateral pneumothorax, which was treated successfully by inserting bilateral chest tubes. In the absence of chronic lung disease, especially bronchitis and emphysema, a diagnosis of iatrogenic pneumothorax was made.

Gas exchange and hemodynamics in experimental pleural effusion.

To investigate the cardiorespiratory effects of graded bilateral pleural effusions in the anesthetized pig. Prospective, randomized, controlled, laboratory study. Animal laboratory. Eleven male Yorkshire pigs. Animals were anesthetized using inhaled isoflurane. Orotracheal intubation was followed by mechanical ventilation. Bilateral chest tubes were inserted, and graded increasing pleural effusions were created using saline of 0, 20, 40, and 80 mL/kg, divided equally between each side. At each pleural volume, intravascular volume was randomly altered (by phlebotomy or transfusion of colloid) to normal (unchanged), low (decreased by 10 mL/kg), or high (increased by 10 mL/kg). Hemodynamic parameters, intrapleural pressures, hemoglobin, and blood gases were measured. At the lowest volume of pleural fluid, PaO2 was reduced by approximately 50% vs. baseline, whereas systemic hemodynamics were unchanged. PaO2 was reduced in a dose-dependent fashion as pleural volume increased but was not affected by alterations in intravascular volume. Intrapulmonary shunt was increased both by intrapleural volume in a dose-dependent fashion and by increases in intravascular volume at high levels of pleural volume. Cardiac output and systemic mean arterial pressure increased with elevated intravascular volume but were not influenced by lower levels of intrapleural volume. Mean pulmonary arterial pressure, central venous pressure, and pulmonary artery occlusion pressure were increased by elevations in both intrapleural volume and intravascular volume. Intrapleural pressure and pulmonary vascular resistance were related to intrapleural volume only. Hypoxemia occurs as an early event in acute bilateral pleural effusions and precedes hemodynamic decompensation. Oxygenation is independent of intravascular filling pressures, but hemodynamics are preserved with elevated filling pressures. Clinical studies should be undertaken to examine the risks/benefits of careful removal of pleural fluid in patients with pleural effusions, when oxygenation is impaired during mechanical ventilation.

Tension pneumothorax complicating diagnostic upper endoscopy: a case report

Hypoxemia is common during various endoscopic procedures and may result from a variety of causes. These causes range from benign and otherwise easily reversible events like oversedation to potentially life threatening complications such as pneumothorax. Although pneumothorax has been reported secondary to gastrointestinal perforation as a complication of various therapeutic endoscopic procedures, there has been no report of pneumothorax without perforation. We report a case of a patient who developed severe hypoxemia and hemodynamic instability during diagnostic upper endoscopy as a result of pneumomediastinum and tension pneumothorax in the absence of any signs of gastrointestinal perforation and comment on various possible mechanisms. Immediate endotracheal intubation and bilateral chest tube placement resulted in prompt return of the patient’s oxygenation and vital signs back to normal. This report enlarges the list of possible causes of hypoxemia during endoscopy and shows the importance of early and prompt recognition, which allowed directed therapy with a good outcome.

A new ventilator improves CO2 removal in newborn lambs with congenital diaphragmatic hernia.

To demonstrate improved ventilation with intratracheal pulmonary ventilation (ITPV) in new-born lambs with congenital diaphragmatic hernia, using a new microprocessor controlled ITPV-specific ventilator. Prospective study, with each animal serving as its own control (paired data). Large animal research laboratory. Diaphragmatic hernias were created surgically in seven fetal sheep on gestational day 100 (term = 145 days). Lambs (2.7 to 5.0 kg) were delivered by cesarean section anywhere between gestational days 136 and 140. Arterial and venous catheterizations, bilateral chest tube thoracostomies, and tracheostomies were performed while the lambs received placental bypass. Initially, congenital diaphragmatic hernia lambs were supported on conventional pressure control mechanical ventilation to achieve steady state with measurements of baseline vital signs, arterial blood gases, and ventilatory settings. ITPV was instituted while maintaining constant peak carinal pressures and oxygen saturations. Statistical comparisons were made using the paired t-test. Postductal Paco2 decreased from 110+/-21 (SD) torr (14.7+/-2.8 kPa) to 52+/-24 torr (6.93+/-3.2 kPa; p= .0014) on ITPV. Simultaneously, pH improved from 7.04+/-0.07 to 7.31+/-0.15 (p = .0012) and minute ventilation increased from 0.66+/-0.40 to 4.00+/-1.35 L/min (p = .0016). Peak carinal pressures and postductal Pao2 were unchanged. ITPV significantly improved CO2 removal in newborn lambs with diaphragmatic hernias without increasing airway pressures or changing oxygenation. Based on these results, we are conducting human clinical trials.

Pneumonias, Asthma, Pneumothorax, and Respiratory Arrest Caused by a Tracheal Mass

Primary tracheal tumors are exceedingly rare.1-3 Tumors of the larynx and lungs respectively occur 75 and 180 times more frequently than tracheal tumors.3Tracheal tumors of neurogenic origin are even rarer.1,4-7 We are aware of only 29 tracheal tumors of neurogenic origin described in the literature, of which 11 have been neurofibromas.3 Most cases go unrecognized for months or years, because the tracheal lumen is often more than 75% occluded before symptoms occur.8 Patients generally have diagnoses of asthma. The correct diagnosis is frequently made when patients respond poorly to conventional asthma treatment.2 We report a case of a child with pneumothoraces and acute respiratory failure caused by an endotracheal neurofibroma. This previously healthy 10-year-old boy was hospitalized with fever and respiratory distress. A diagnosis of pneumonia was made with radiographs, showing bibasilar infiltrates. He was treated with intravenous antibiotics. Two months later, he had a second episode of pneumonia and again was hospitalized. Chest radiographs again showed bibasilar pneumonia. During this admission, wheezing was noted, and a diagnosis of asthma was made. There were no previous asthma symptoms, and pulmonary function tests were never performed. However, there was a maternal family history of asthma. The patient subsequently had multiple visits …

Pleural drainage after repair of tetralogy of Fallot.

Prolonged pleural effusion after congenital heart surgery results in extended hospitalization. Pleural drainage was evaluated in 39 consecutive patients undergoing repair of tetralogy of Fallot, to identify risk factors for persistent pleural effusion. Duration and amount of drainage was examined by the Kaplan-Meier method and risk factors were evaluated by univariable and multivariable analyses. Median time of pleural drainage was 6.1 days, range 3 to 42 days. Duration of pleural drainage correlated with length of hospital stay (p < 0.0001). Postrepair right atrial pressure (p = 0.018) and preoperative hemoglobin (p = 0.035) were risk factors for persistent drainage. The presence of a previous right thoracotomy reduced drainage duration (p = 0.034). Prolonged mechanical ventilation increased the average daily volume of effusion (p < 0.0001). In conclusion, prolonged pleural effusion is an important morbidity factor after repair of tetralogy of Fallot. Bilateral chest tube insertion is indicated in patients with high preoperative hemoglobin and elevated postrepair right atrial pressure. Right thoracotomy is the preferred surgical approach when a preliminary palliative shunt is required.

Descending Necrotizing Mediastinitis: Surgical Treatment Via Clamshell Approach

Background. Descending necrotizing mediastinitis requires an early and aggressive surgical approach to reduce the high morbidity and mortality associated with this disease. The clamshell incision has provided excellent exposure of the entire mediastinum and both pleural cavities and was assessed in patients suffering from descending necrotizing mediastinitis. Methods. Three patients with descending necrotizing mediastinitis and bilateral pleural empyema due to invasive streptococcal infections were operated on with this method. Radical debridement of the mediastinum and bilateral decortication was performed through a clamshell incision, including pericardiectomy in 2 patients. All patients received initially a high dose of antibiotic regimen, 2 had bilateral chest tube drainage, and 1 had mediastinal drainage and pleural debridement via cervical mediastinotomy and thoracoscopy, respectively. All these measures alone, however, failed to control the disease. Results. The clamshell incision offered an excellent exposure for bilateral decortication and debridement of the entire mediastinum including pericardiectomy. One patient, who was referred in critically ill condition, died of multiorgan failure in the postoperative period. The remaining 2 patients recovered without further interventions and without evidence of phrenic nerve palsy, sternum osteomyelitis, or sternal override. Conclusions. The clamshell approach offers an excellent exposure for a complete one-stage surgical treatment with mediastinal debridement and bilateral decortication in patients suffering from descending necrotizing mediastinitis in the absence of profound septic shock.

Laparoscopic posterior partial fundoplication: analysis of 100 consecutive cases.

Performance of a laparoscopic posterior partial fundoplication (LPPF) for severe gastroesophageal reflux disease may have significant advantages. These include a low incidence of postop dysphagia, maintenance of the ability to belch, excellent antireflux effects, and the ease of performance of the surgery. The purpose of this study was to evaluate this antireflux procedure for these advantages to determine both its safety and effectiveness. Over 200 LPPFs have been performed by the authors in a community setting. One hundred consecutive cases are evaluated for indications, preop, and postop studies (EGD, manometry, 24 h pH), time of operation, hospital stay, complications, and conversions to an open procedure. Our technique of LPPF is presented in detail. All patients maintained the ability to belch. Postop dysphagia resolved totally in 4 patients by 7 days. Four pneumothoraces occurred; 1 patient required bilateral chest tube placement. There were no esophageal, stomach, or splenic injuries. The average hospital stay was 1.6 days. Postop 24 h pH studies revealed resolution of the esophageal reflux. Postop manometric studies show a median increase of 9.2 mm Hg for the LES pressure. No patients have resumed antireflux medication. No short gastric vessels were divided and no esophageal sutures were placed. There were no conversions to a laparotomy. Laparoscopic posterior partial fundoplication is a safe and effective antireflux procedure.

Hydrops fetalis and pulmonary sequestration

The development of fetal hydrops in conjunction with intrathoracic pathology has been described, but rarely in association with pulmonary sequestration. The current report presents three cases of antenatally identified nonimmune hydrops fetalis, seen in association with pulmonary sequestrations. In one case, a left-sided chest mass also was defined. One infant was born by emergency cesarean section because of fetal distress at 34 weeks' gestation; the other two were delivered vaginally at 30 and 36 weeks. Two of the newborns were severely hydropic and required aggressive cardiorespiratory resuscitation that included bilateral chest tubes for massive pleural effusions. The third infant was stable at the time of birth, but thereafter respiratory distress developed, and intubation and ventilation became necessary. Two of the infants had a left-chest mass and the other had a right-sided mass, all identified by chest x-ray. Subsequent ultrasonography showed a chest mass and an identifiable systemic feeding artery in two of the patients. For the third, a specific diagnosis was not made before surgery. After resolution of hydrops, all three infants had successful removal of their intrathoracic pulmonary sequestrations. Two of these were found to be extralobar, and the other was an intralobar sequestration of the left lower lobe.

Extracardiac modification of the Fontan operation without use of prosthetic material

Extracardiac modification of the Fontan operation without use of prosthetic material

Induction of Wide QRS Tachycardia During Transthoracic Echocardiography

A wide QRS tachycardia was repeatedly triggered during transthoracic echocardiographic examination in a critically ill premature infant with bilateral chest tubes. The left-sided tube was anterior to the heart. The arrhythmia was not induced after removal of the chest tubes at the follow-up ultrasonographic evaluation. Compression of the thoracic wall and chest tube, and subsequently the heart, by the ultrasound transducer is postulated as the cause for this wide QRS tachycardia.

Effect of thoracic venting on arterial pressure, and flow during external cardiopulmonary resuscitation in animals.

To test the hypothesis that fluctuations in global intra-thoracic pressure are the dominant cause of blood flow during external CPR, the authors studied the effects of open pneumothorax on experimental CPR in 7 domestic pigs and 12 mongrel dogs. Similar studies were conducted independently at three laboratories and are reported jointly. All studies were conducted during electrically induced ventricular fibrillation and with standard CPR technique: ventral-dorsal chest compression at 60/min, 0.5 sec compression duration, 1:5 ventilation:compression ratio. During alternate periods of CPR, intrathoracic pressure was vented through bilateral chest tubes, placed to create open pneumothorax and partial collapse of the lungs. During this maneuver, global intrathoracic pressure fluctuations were greatly attenuated, but direct cardiac compression and adequate ventilation continued. In the three laboratories, systolic/diastolic arterial pressures during CPR with thoracic venting (± se) averaged 68 ± 4.2/28 ± 3.3, 60 ± 10/18 ± 4.5, and 66 ± 6.3/23 ± 1.5 mm Hg. These values are compared to 68 ± 4.4/27 ± 3.0, 67 ± 12/17 ± 6.1, and 56 ± 6.2/22 ± 1.9 mm Hg with the thorax intact. Carotid artery mean flow, measured with an in-line flowmeter, was 13.0 ± 2.2 ml/min vented vs. 13.4 ± 2.6 intact in 7 pigs; 11.4 ± 3.8 ml/min vented vs. 11.2 ± 3.7 intact in 5 dogs. Cardiac output, determined by indicator dilution, was 25 ± 4.3 ml/min · kg vented vs. 20 ± 4.3 intact in 7 dogs. Thoracic venting did not decrease blood pressures and flows during CPR, as would be predicted from the hypothesis that generalized intrathoracic pressure fluctuations are the dominant hemodynamic mechanism. The results are consistent with the classical notion that CPR works by compression of the heart between the sternum and the spine. This mechanism should not be discounted in future attempts to improve CPR.