Closed Chest Drainage Research Articles

Patent conversion of a novel closed chest drainage device

Closed chest drainage is typically necessary following Lobar and Sublobar resections to evacuate gases and fluids from the thoracic cavity, eliminate residual pleural space for lung expansion, and maintain negative pressure. Currently, three conventional closed chest drainage systems are commonly employed: single-chamber, double-chamber, and triple-chamber systems; each system has its own advantages and disadvantages. Despite the emergence of digital drainage systems in recent years, their high cost hinders their widespread adoption. Based on this premise, our research team has achieved a patent for a micro air pump-integrated chest closed drainage bottle, which has been further developed into a novel device integrating a three-chamber system with negative pressure control and power supply capabilities. This device enables patients undergoing perioperative lung procedures to ambulate freely while simultaneously receiving chest suction therapy—a concept that theoretically promotes rapid postoperative recovery. Moreover, this device offers economic benefits and holds potential for clinical implementation (particularly in economically underdeveloped regions). In this article, we modified the thoracic closed drainage device based on our patent and presented this novel thoracic closed drainage device after 3D printing and assembly.

Application of a standardized early activity program on enhanced recovery after surgery in patients after surgery for pulmonary nodules.

Early postoperative activity, an important part of enhanced recovery after surgery (ERAS) in clinical practice, is considered to be a significant component of postoperative quality care. To evaluate the effect of a standardized early activity program on ERAS in patients after surgery for pulmonary nodules. A total of 100 patients with pulmonary nodules who underwent a single-port thoracoscopic segmental resection or a wedge resection of the lung were selected for the present study. These patients were divided into a control group (n= 50) and an intervention group (n= 50) by a digital random method. The patients in the control group received routine perioperative nursing intervention for thoracic surgery due to lung cancer, and those in the intervention group received an intervention using a standardized early activity program along with routine nursing care. The evaluation indexes in both groups included postoperative indwelling time of the closed chest drainage tube, the time to the first off-bed activity after surgery, the incidence of postoperative pulmonary complications, the length of postoperative hospital stay, and patient satisfaction. The postoperative indwelling time of the closed chest drainage tube and the time to the first off-bed activity in the intervention group were less than in the control group. The length of the postoperative hospital stay in the intervention group was shorter than in the control group, and the patient satisfaction in the intervention group was higher than in the control group. The difference for these evaluation indexes were statistically significant (P< 0.05). The number of cases of postoperative complications was four and eight in the intervention group and the control group, respectively, and the difference was not statistically significant (P> 0.05). A standardized early activity program is a safe and effective nursing measure for ERAS for patients after surgery for pulmonary nodules, which can promote earlier off-bed activity, shorten the postoperative indwelling time of the closed chest drainage tube, shorten the postoperative hospital stay, improve patient satisfaction, and promote rapid recovery.

Does the timing of surgery affect outcomes in young and middle-aged patients undergoing surgical stabilization of rib fractures? Feedback was based on real data from physicians, patients, and family caregivers.

There is a general clinical consensus that early surgical stabilization of rib fractures (SSRF, ≤ 48-72h after admission) can benefit patients, and this is only regarding the surgeon's opinions. This study assessed the true outcomes of young and middle-aged patients at different surgical timings. This retrospective cohort study was conducted among patients aged 30-55years who were hospitalized with a diagnosis of isolated rib fractures and underwent SSRF between July 2017 and September 2021. The patients were divided into early (≤ 3days), mid- (4-7days) and late (8-14days) groups, according to the interval (days) between surgery and injury date. The impact of different surgical timings on clinical outcomes, patients, and families was assessed by comparing SSRF-related data during hospitalization and follow-up studies of clinicians, patients themselves, and family caregivers 1-2months after surgery. In this study, 155 complete patient data were finally included, including 52, 64, and 39 patients in the early, mid, and late groups, respectively. Length of operation, preoperative closed chest drainage rate, length of hospital stay, intensive care unit length of stay, duration of invasive mechanical ventilation in the early group were lower than those in the intermediate and late groups. Additionally, hemothorax and excess pleural fluid incidence after SSRF was lower in the early group than in the intermediate and late groups. Postoperative follow-up results showed that patients in the early group had higher SF-12 physical component summary scores and shorter duration of absence from work. Family caregivers had lower Zarit Burden Interview scores than those in the mid- and late groups. From the experience of our institution's SSRF, early surgery is safe and offers additional potential benefits for young and middle-aged patients and families with isolated rib fractures.

Diagnosis and treatment of tuberculosis presenting as uveitis based on stochastic simulation in systems biology

ABSTRACT Tuberculous uveitis can be a manifestation of extrapulmonary tuberculosis or an allergic reaction to tuberculosis infection. The clinical signs and symptoms of other uveitis causes are generic, making a false diagnosis simple. We present a brief introduction to theoretical modelling and simulation in systems biology and explore the consequences of TB uveitis if left untreated. Patients were admitted to our hospital with recurrent fever. They had a previous definitive diagnosis of binocular uveitis and a positive interferon gamma release assay (IGRA) test result. At the time, there was no antituberculosis medicine available, and immunosuppressive and glucocorticoid therapy did not work. After the admission, their pleural fluid tested positive for Mycobacterium tuberculosis. No other causes to explain the fever were found. A diagnosis of tuberculosis was made, and their body temperature normalized after antituberculosis treatment and closed chest drainage. Vigilance should be exercised to rule out tuberculous uveitis in cases of unexplained uveitis; this calls for IGRA screening, tuberculin skin testing, and cyst imaging. For patients with latent tuberculosis infections, it is recommended to administer antituberculosis treatment, after excluding other possible causes, and to avoid using glucocorticoids in isolation.

Hand-Schüller-Christian syndrome combined with empty sella syndrome: A case report and literature review.

Hand-Schüller-Christian syndrome (HCS) is a rare disease with little clinical awareness, but the condition is more dangerous, and it combines with empty sella syndrome (ESS) which is extremely rare. A 26-year-old male patient who had proptosis, headaches, and diabetes insipidus for more than 10 years, and chronic cough and wheeze for 8 years presented to our hospital due to an abrupt onset of chest pain for 2 days. Hand-Schüller-Christian syndrome is diagnosed based on the typical clinical manifestations of diabetes insipidus and bilateral proptosis, magnetic resonance imaging (MRI) pituitary imaging and pathology. Empty sella syndrome is diagnosed based on hormonal indicators, clinical manifestations and MRI pituitary scan results. Type 1 respiratory failure and severe pneumonia can be diagnosed based on the results of clinical examination, chest imaging (including chest x-ray and computed tomography), pathology and blood gas analysis. Left pneumothorax can be diagnosed with chest imaging. "Meropenem and Cefdinir" were given for antimicrobrial coverage, "Desmopressin acetate" for anti-diuretic treatment, "Forcodine" for cough relief, "Ambroxol and acetylcysteine" for phlegm reduction, and continuous closed chest drainage was performed. The patient discharged after cough, wheezing, headache and other symptoms improved, and vital signs were stable. The patient has been followed up once a month for 17 months ongoing after discharge. At present, symptoms such as cough, sputum, and wheezing have improved considerably, and the mMRC score of dyspnea is 2 points. The reexamination of the chest X-ray shows that the absorption of lung exudates is better than before, and there is no recurrence of pneumothorax. Consider whether isolated diabetic insipidus is related to HSC, and if so, conduct an MRI, a biopsy, and other examinations as soon as possible.

Clinical characteristics and diagnosis and treatment strategies of patients with severe traumatic aortic injury

Objective: To investigate the clinical characteristics and diagnosis and treatment strategies of patients with severe traumatic aortic injury (TAI). Methods: A total of 25 patients with TAI, who hospitalized in our hospital between August 2005 to March 2021 and underwent thoracic aortic endovascular repair (TEVAR), were included in this retrospective study. According to the time from admission to TEVAR, the patients were divided into emergency TEVAR group (14 cases, TEVAR within 24 h of admission) and elective TEVAR group (11 cases, patients underwent surgery or fracture reduction and fixation first for serious injuries and then underwent TEVAR more than 24 h after admission). The general clinical data of patients, injury severity score (ISS), time from admission to intervention, total hospital stay, the proportion of closed chest drainage and the proportion of abdominal organ repair were obtained and compared. Clinical follow-up and 1-year postoperative aortic computed tomography angiography (CTA) were performed on the patients. Death, the occurrence of aortic adverse events and injury recovery were followed up and recorded. Results: The mean age of these 25 TAI patients was (41.4±14.4) years, 20 patients were males (80.0%). 21 patients (84.0%) had persistent chest and back pain, 17 (68.0%) had pleural effusion and 5 (20.0%) had mediastinal hematoma. The injury severity score (ISS) was significantly higher in the elective TEVAR group than in the emergency TEVAR group (24.9±14.4 vs. 35.5±9.3, P=0.044). The time from admission to intervention ((1.0±0.0) d vs. (3.4±0.9) d, P<0.001], the time from admission to TEVAR ((1.0±0.0) d vs. (11.5±13.8) d, P=0.030) and total hospital stay ((6.1±2.3) d vs. (26.8±7.7) d, P<0.001) were significantly longer in elective TEVAR group than in emergency TEVAR group. The proportion of thoracic closed drainage was significantly lower in the elective TEVAR group than in the emergency TEVAR group (9 (64.3%) vs. 2 (18.2%), P=0.042). The proportion of abdominal organ repair was significantly higher than in the emergency TEVAR group (0 vs. 4 (36.4%), P=0.026). All of 25 patients were discharged alive and followed up for (84.0±30.5) months. All patients survived and completed 1-year postoperation CTA. There were no aortic adverse events occurred, and no complications after surgery, and the fractures and organ injuries healed well. Conclusions: The clinical characteristics of severe TAI are acute multi-injuries combined with persistent chest and/or back pain, pleural effusion, and mediastinal hematoma. Timely diagnosis and treatment are important factors for the outcome. The treatment strategy for multi-injuries should give priority to dealing with life-threatening injuries. TEVAR is the primary treatment strategy for severe TAI and is related to satisfactory outcomes.

Study on the Application of A New Type of Anhydrous Thoracic Negative Pressure Drainage Device in Patients after Thoracic Surgery

背景与目的胸外科术后常规会放置胸管行闭式引流排出胸腔内积气、积液促进肺复张，并且可以观察术后是否有活动性出血，是否有肺漏气现象。常规胸腔闭式引流外接水封瓶，通过观察引流情况、水柱波动来判断病情，是非常经典的方法。但是水封瓶有易倾覆、携带不便等缺点，不利于患者早期活动。在加速康复的理念下，本中心应用了新型无水胸腔负压引流装置，并取得了较好的效果。本研究旨在观察新型无水胸腔负压引流装置在胸外科术后患者中的应用效果。方法回顾性分析2018年1月-2019年12月在浙江大学医学院附属第一医院胸外科行肺部手术的患者，分成两组，一组患者使用传统胸腔闭式引流水封瓶作为对照组，另一组使用新型无水负压引流瓶作为实验组。统计患者的性别、年龄、高血压、糖尿病、吸烟史、手术切口和手术方式以及患者在院时间和术后住院时间。结果两组患者在年龄、性别、合并症（高血压、糖尿病、吸烟史）、手术范围、手术时间方面并无统计学差异，但是两组患者在手术使用切口方面存在着统计学差异（P=0.01）。使用新型无水负压引流器的患者无论在术后住院时间以及总住院时间方面都比有水负压引流器的患者短，差异有明显统计学意义（P=0.02, P=0.04）。结论新型无水胸腔负压引流装置对于胸外科术后快速康复推进有较好的作用。

The Innovated "Closed Chest Drainage System" of William Smoult Playfair (1871).

During the 19th century, the addition of the water-seal system to a closed chest drain was a major turning point in the history of thoracic surgery. German physician Gotthard Bülau seems to have invented and used his own closed chest drainage device with a liquid-seal system in 1875, and published it in the year 1891. But, in 1871, British physician William Smoult Playfair seems to have thought of the subaqueous drainage and used such drainage to treat the thoracic empyema in children. The British physician stresses in his texts the effectiveness of his method of fully draining the thoracic empyemas while simultaneously preventing air from entering the pleural cavity. An appropriate honor must be attributed to Playfair, who used a subaqueous chest drainage system and appears to be the first to publish such a method.

Retrospective Analysis of Single Closed Chest Drainage in Superior Lobectomy of Lung Cancer

背景与目的目前，肺上叶切除术后留置单管胸腔引流还是双管胸腔引流管仍存在争议，本研究对因肺癌行肺上叶切除术、常规淋巴结清扫术后留置单根胸腔闭式引流管患者的术后引流相关并发症进行统计分析，评价引流效果。方法回顾性分析2012年4月-2017年5月入住北京友谊医院胸外科因肺癌行肺上叶切除术、常规淋巴结清扫术后放置单根引流管患者的临床资料，评价单根胸腔闭式引流管的引流效果。结果301例患者行肺上叶切除术、常规淋巴结清扫术后放置单根胸腔引流管，术后并发症发生率为9.3%，其中胸腔引流管相关并发症占5.64%。结论肺上叶切除术、常规淋巴结清扫术后单管胸腔闭式引流的引流效果不亚于双管引流。

Chest tube simulator: development of low-cost model for training of physicians and medical students.

by using a 3D printer, to create a low-cost human chest cavity simulator that allows the reproduction of the closed chest drainage technique (CCD), comparing its effectiveness with that of the animal model. it was made a 3D printing of the bony framework of a human thorax from a chest computerized tomography scan. After printing the ribs, we performed tests with several materials that contributed to form the simulation of the thoracic cavity and pleura. An experimental, randomized, and controlled study, comparing the efficacy of the simulator to the efficacy of the animal model, was then carried out in the teaching of CCD technique for medical students, who were divided into two groups: animal model group and simulator model group, that trained CCD technique in animals and in the simulator model, respectively. the chest reconstruction required anatomical knowledge for tomography analysis and for faithful 3D surface editing. There was no significant difference in the safety of performing the procedure in both groups (7.61 vs. 7.73; p=0.398). A higher score was observed in the simulator model group for "use as didactic material" and "learning of the chest drainage technique", when compared to the animal model group (p<0.05). the final cost for producing the model was lower than that of a commercial simulator, what demonstrates the feasibility of using 3D printing for this purpose. In addition, the developed simulator was shown to be equivalent to the animal model in relation to the simulation of the drainage technique for practical learning, and there was preference for the simulator model as didactic material.

Usefulness of routine computed tomography in the evaluation of penetrating war injuries to the chest.

This review was conducted to compare the contributions of chest X-ray (CXR) and computed tomography (CT) towards detecting intrathoracic damage in patients with penetrating war injuries to the chest and to determine whether identification of additional injuries by chest CT will have an impact on the choice of therapeutic interventions and clinical outcomes. We reviewed records of 449 patients (374 men, mean age 29.3 ± 14.8 years) who were admitted to our hospital with penetrating war injuries to the chest over a 7-year period. Collected data included mechanisms of injury, associated injuries, results of CXRs and chest CTs, methods of management, in-hospital stays, complications and mortalities. Immediate screening CXRs were obtained in all patients not requiring emergent thoracotomies, of which 91.4% showed positive signs of injury. Chest CTs were performed at the discretion of the physicians in 49.4% of patients, and CXR-positive findings were confirmed in all cases, while revealing additional injuries in 11% of patients. Chest CT findings led to additional closed chest drainage in 5.6% of patients but had no impact on treatment strategy in 94.4% of scanned patients. Follow-up CXRs showed new positive findings in 22 patients, leading to additional closed chest drainage in 3 patients and delayed open thoracotomies in 7 other patients. CXRs continue as the primary diagnostic modality in the assessment of patients with penetrating war injuries to the chest. Chest CTs can be omitted in most patients, thus reducing CT imaging case-load substantially, while most clinically significant chest injuries remain sufficiently recognized.

Dysfunctional Closed Chest Drainage - Common Causative Factors and Recommendations for Prevention.

IntroductionDysfunctional closed chest drainage unit (CDU) dysfunction is a common but serious clinical problem associated with tube thoracostomy and results in a significant rise in morbidity, prolonged hospital stays, and increased economic burden. This observational study examines the proximate factors of closed CDU dysfunction in addition to their relative frequency. Based on our findings, we suggest logical recommendations for preventing the factors that contribute to closed chest drainage unit dysfunction.MethodThe study target population consists of all those individuals who had experienced tube thoracostomy for any pathology related to the chest cavity treated in the Department of Thoracic Surgery, Nishter Medical University, Multan, Pakistan, from February 2015 to January 2017. The study population was not restricted by age or gender. Of the 727 examined cases, only those patients who had experienced tube thoracostomy and had significant failure in draining the pleural collection were included in the study. Detailed histories were collected, and thorough physical examinations were carried out for each participant. Chest x-rays and, if needed, computed tomography (CT) scans were obtained to properly examine the placement of the chest tubes and detect the causative factor of the closed CDU dysfunction.ResultsA total of 139 cases were included in the study. The most common cause of closed CDU dysfunction was the use of the wrong CDU connection (n = 24, 17.3%). Other common problems included inadequate prime fluid use, loose connections, kinked tubes, and overly full bottles.ConclusionClosed CDU dysfunction may be prevented by adopting and following proper protocols for tube thoracostomy.

Comparison of closed-chest drainage with rib resection closed drainage for treatment of chronic tuberculous empyema.

This study aimed to compare the efficacy of closed-chest drainage with rib resection closed drainage of chronic tuberculous empyema. This retrospective study reviewed 86 patients with tuberculous empyema in Shanghai Pulmonary Hospital from August 2010 to November 2015. Among these included patients, 22 patients received closed-chest drainage, and 64 patients received rib resection closed drainage. The results showed that after intercostal chest closed drain treatment, 2 (9.09%) patients were recovery, 13 (59.09%) patients had significantly curative effect, 6 (27.27%) patients had partly curative effect, and 1 (4.55%) patient had negative effect. After treatment of rib resection closed drainage, 9 (14.06%) patients were successfully recovery, 31 (48.44%) patients had significantly curative effect, 19 (29.69%) patients had partly curative effect, and 5 (7.81%) patients had negative effect. There was no significant difference in the curative effect (P>0.05), while the average catheterization time of rib resection closed drainage (130.05±13.12 days) was significant longer than that (126.14±36.84 days) in course of intercostal chest closed drain (P<0.05). This study had demonstrated that closed-chest drainage was an effective procedure for treating empyema in young patients. It was less invasive than rib resection closed drainage and was associated with less severe pain. We advocated closed-chest drainage for the majority of young patients with empyema, except for those with other diseases.

&lt;b&gt;Institutional protocol to standardize the chest drainage system management, from surgery to nursing care, at a regional hospital in northern Paraná

The purpose of chest drainage is to allow lung re-expansion and the reestablishment of the subatmospheric pressure in the pleural space. Properly managing the drainage system minimizes procedure-related complications. This prospective observational study evaluated adult patients undergoing water-seal chest drainage, admitted to our hospital and accompanied by residents and tutors, aiming to check their care. One hundred chest drainages were monitored. The average age was 38.8 years old. The average drainage time was 6.7 days. Trauma was the prevalent cause (72%) for the indication of pleural drainage. The obstruction of the system occurred in 6% of the cases; 5% subcutaneous emphysema, 1% infection around the drain; 5% accidental dislodgement of the drain, and in 5% of the patients, there were some complications when removing the drain. Failures in chest drainage technique and management were present, and reflected in some complications that are inherent to the procedure, although it is known that there are intrinsic complications. This study aimed to assess the management of closed chest drainage systems and standardize the care provided in such procedure.

Strategies of the treatment of spontaneous esophageal rupture: Report of thirteen cases from Xingtai, Hebei Province, China

Aims and Objectives: To explore the treatment of spontaneous esophageal rupture.Materials and Methods: The treatments of thirteen patients hospitalized with spontaneousesophageal rupture were analyzed retrospectively. Initially three cases of hospitalized patients were given operative treatments. During the surgery, food residue and necrotic tissue were removed, and repair of esophageal rupture and jejunostomy were implemented. One closed chest drainage tube was placed at the end of the surgery. All the patients were given nutritional support through vein and nutrient canal placed into the jejunum. The remaining ten cases were given conservative treatments. Early treatments included closed chest drainage, and irrigation with normal saline by the patients’ swallowing. At the same time were given intravenous nutrition. When the patients’ conditions were improved, three cases were given nutrition through nasogastric tube at the same time. The remaining seven cases were given jejunostomy and were given nutritional support through vein and nutrient canal placed into the jejunum.Results: In the fi rst 3 patients, who were given emergency operative treatments, two cases died, only single case (33%) recovered. In the other ten cases, one case gave up treatment and discharged from hospital (died of infection with multiple organ failure after discharge). One case had encapsulated pyothorax with atelectasis after chest drainage, and the healing of esophagus rupture were infl uenced, so at the 25th day after esophageal rupture, pyothorax removal and repair of esophageal rupture were implemented, and the patient was recovered well after surgery. The rest eight cases were recovered well after closed chest drainage treatment (80%) without surgery.Conclusion: For the treatment of spontaneous esophageal rupture, we think that it should be given priority to conservative treatment. With adequate drainage and irrigation, and keeping balance of nutritional condition and water-electrolyte, a good therapeutic effect can usually be achieved.Asian Journal of Medical Sciences Vol. 7(3) 2016 89-93

High-risk primary disease and medical factors of ventilator-associated pneumonia in neonates: A Meta-analysis

Objective To provide the evidences for the management strategies of ventilator-associated pneumonia (VAP) in neonates, we systematically reviewed all related studies and analyzed the high-risk primary disease and medical factors of VAP in neonates. Methods We retrieved all related studies in CNKI, Wan-fang, VIP, CBM, Pubmed and Embase and evaluated their quality by Newcastle-Ottawa Scale and analyzed all data by qualitative and Meta-analysis. Results There were 12 case-control studies with higher methodological quality and involving 1 994 neonates and with 708 VAP patients. Six studies involving 872 neonates were in-cluded, the odds ratio of respiratory distress syndrome(OR=2.81) and malnutrition(OR=5.18) had significant differences between VAP and non-VAP group. Seven studies involving 1 110 neonates were included and the odds ratio of patients with corticosteroids (OR=3.12), central inhibitors (OR=2.31), antacids (OR=4.35) and Gamma globulin with large doses (OR=2.35) had significant differences between VAP group and non VAP. Four studies involving 554 neonates were included and the odds ratio of patients with closed chest drainage (OR=1.81)and umbilical vein catheterization (OR=9.19) had significant differences between VAP group and non VAP. Six studies involving 1 139 neonates were included and the odds ratio of patients with parenteral nutrition (OR=1.82)and blood transfusions (OR=2.49) had significant differences between VAP group and non VAP. Conclusions Our study confirms that the respiratory distress syndrome and malnutrition corticosteroids, central inhibitors, antacids, Gamma globulin with large doses, closed chest drainage, umbilical vein catheteriza-tion, parenteral nutrition and blood transfusions are important risk and early-warning factors. Key words: Neonates; Ventilator-associated pneumonia; Primary disease; Medical factors; Meta-analysis

Value of C-arm computed tomography in radiofrequency ablation of small lung lesions.

This study aimed to explore the value of C-arm computed tomography (CT) applications in radiofrequency ablation (RFA) of small lung lesions. The puncture success rate, cumulative survival rate, tumor response rate, complications, and radiation dose during C-arm CT-guided RFA of 36 small lung lesions in 34 patients were analyzed. In 35 RFA procedures for 36 small lung lesions, the puncture success rate was 100%. There were 7 cases of complications, including 4 cases of pneumothorax (puncture suction or closed chest drainage was not required) and 3 cases of hemoptysis. The cumulative survival rate in the 34 patients after RFA was 100% at 6 months, 69.0% at 1 year, and 60.0% at 2 years. In assessments of 36 foci imaged during the follow-up period, the total response rates at 1 month, 3 months, and 6 months were 77.8% (28/36), 69.7% (23/33), and 61.3% (19/31), respectively. The mean cumulative dose and average effective dose during surgery were 120.1 ± 61.4 mGy and 3.5 ± 1.7 mSv, respectively. The application of C-arm CT to RFA of small lung lesions could provide abundant information to the surgeon and increase the lesion puncture success rate and is considered to be a promising image-guided technology.

Congenital chylothorax and pulmonary hypertension complicated with heart failure and hepatopathy

Respiratory difficulty resulting from congenital chylothorax is usually relieved by postnatal thoracentesis, closed chest drainage, and oxygen therapy. However, early occurrence of congenital chylothorax or accumulation of a large amount of chylous fluid sometimes leads to pulmonary hypoplasia or persistent pulmonary hypertension of the newborn, which requires further customized mechanical ventilatory support. In these cases, conventional mechanical ventilation is primarily used during initial treatment and is later replaced by high-frequency ventilation, but the advantages of inhaled nitric oxide treatment have rarely been described. This case suggests the benefits of inhaled nitric oxide in patients with congenital chylothorax, even when mechanical ventilation cannot improve respiratory distress because of severe pulmonary hypertension of the newborn leading to right cardiac dysfunction and possibly cholestasis.

Management of empyema in children: a clinical audit

<h3>Aim</h3> National guidelines for the management of paediatric pleural infections (empyema) were introduced by the British Thoracic Society in 2005, and our institution implemented a trust guideline in 2008. We reviewed the management of empyema in our children9s hospital in accordance with both guidelines. <h3>Methods</h3> Cases of empyema admitted April 2005-March 2011 were identified through clinical coding, surgical, radiological and microbiological databases. Management and clinical course were extracted onto a proforma, following an initial pilot. Findings were presented at the paediatric clinical governance meeting. <h3>Results</h3> 101 children, median age 5.3 (range 0.6 to 16.3) years, were admitted for median 8 (range 2 to 28) days. 23 children (23%), with ultrasound median effusion depth 1.6 cm, were managed conservatively with IV antibiotics alone. Initial surgical management (77%) included 51% closed chest drainage, 23% video-assisted thoracoscopic surgery (VATS) and 3% open thoracotomy. Intrapleural urokinase was used in 89% of the 78 patients surgically managed: 87% with closed chest drain, 70% of VATS and 67% of open thoracotomy procedures. A quarter (24%) of all chest drains dislodged accidentally at a median 3 (range 1 to 6) days after surgery. 13% of those surgically managed required a second procedure. 92 (91%) patients did not have an anti-streptolysin O-titre (ASOT), nor 27 (27%) a blood culture sent. Pleural fluid was sent for culture in 76 (97%) of surgically managed patients, 13 (16%) of these having differential count/cell cytology. There was limited use of pneumococcal PCR in culture negative patients. Initial IV antibiotic use was with Co-Amoxiclav (46%) or Cephalosporins (52%), either alone or in combination with other antibiotics. Total duration antibiotic therapy was median 21 (range 7-40) days, with variation in intravenous and oral course length. <h3>Conclusion</h3> The majority of children were managed according to guidelines. Almost a quarter were managed conservatively. Urokinase use was varied, with shortened courses, and a number of cases of VATS or thoracotomy receiving urokinase. The high rate of drain dislodgement is of concern, and will be addressed by the introduction of pig tail catheters. Trust guidance regarding appropriate investigations have been modified.

Study of clinical treatment of esophageal foreign body-induced esophageal perforation with lethal complications

Esophageal foreign body-induced esophageal perforation is a lethal complication and its treatment very complex. We had reviewed 1,428 patients with esophageal foreign body, who were hospitalized and treated over the past 25 years. A classification summary was made of 121 patients (of these 1,428 cases) who presented with esophageal foreign body-induced perforation and complicated cervical abscess, mediastinitis, and mediastinal abscess. This summary considered foreign body types, location and lodging duration, complications, and surgical approaches. Among these 121 patients, esophageal foreign bodies in 81 patients were successfully extracted via esophagoscope or fiber optic esophagoscope. Cervical esophageal foreign bodies in 22 patients were extracted by esophagoscope and lateral cervical incision (n = 6) and simple lateral cervical incision (n = 16). Thoracotomy was performed to remove thoracic esophageal foreign bodies in 18 patients with 10 successes and 8 failures. Of the 121 patients, 67 patients with cervical abscess were cured by means of lateral cervical abscess incision and drainage, esophageal stent placement, and esophageal perforation repair with pedicle myolemma or pedicle muscular periosteum flap. 54 patients with mediastinitis and/or abscess were all cured, except one mortality, by means of mediastinotomy and drainage or/and closed-chest drainage, simple esophageal repair, esophageal repair with pedicle myolemma or pedicle muscular periosteum flap and stent placement for esophageal perforation, and esophageal exclusion plus two-stage gastric-pharyngeal anastomosis. In the treatment of esophageal foreign body-induced severe complications, various therapies should be applied simultaneously. Lateral cervical incision should be made immediately to remove the foreign bodies if the foreign body extraction under esophagoscope proves to be a failure after repeated attempts, or esophageal perforation develops during the procedure, or should cervical abscess develop. Mediastinotomy and drainage or/and closed-chest drainage should be carried out as early as possible when mediastinitis and/or mediastinal abscess develops after esophageal foreign body ingestion.