Emergency Tube Thoracostomy Research Articles

Recurrent thoracic air leak syndrome in patients affected by pulmonary graft-versus-host disease: Surgical strategies and outcome.

Thoracic air leak syndrome (TALS) is a complication related to chronic pulmonary graft-versus-host disease (pGvHD) that affects approximately 0.83%-3.08% patients after allogenic hematopoietic stem cell transplant. Such complication is defined as the occurrence of any form of air leak in the thorax, including spontaneous pneumomediastinum or pneumopericardium, subcutaneous emphysema, interstitial emphysema and pneumothorax and has a negative impact on post-transplant survival. The aim of the present study is to describe a single-center experience in the surgical management of recurrent TALS in adolescents and young adults and its outcome. We retrospectively reviewed the clinical notes of patients with previous allogenic hematopoietic stem cell transplant who underwent surgical procedures for recurrent TALS from January 2016 until March 2021. We analyzed clinical data, number of episodes of thoracic air leak, surgical procedures and relative outcome. In the examined period, four patients, aged 16-25 years, underwent surgical procedures for TALS, including thoracostomy tube placement, thoracoscopic pleurodesis and thoracotomy. All the patients had been diagnosed with pGvHD before the onset of TALS, with a mean time lapse of 276 days (range 42-513). These patients experienced on average 4.5 air leak episodes (range 3-6). All the patients experienced at least two episodes before surgery. One patient underwent emergency tube thoracostomy only, three patients underwent thoracoscopic pleurodesis and two patients underwent thoracotomy. After surgery, patients were free from air leak symptoms for a mean time of 176 days (range 25-477). Pulmonary function progressively deteriorated, and all the patients eventually died because of respiratory failure after a mean time of 483 days (range 127-1045) after the first episode of air leak. Surgery provides temporary relief to symptoms related to TALS but has limited effects on the underlying pathophysiologic process. The development of TALS in a sign of progressive pulmonary function worsening and is associated with high risk of respiratory failure and mortality.

Post-COVID recurrent dyspnoea

Rationale: Post-COVID symptoms need aggressive evaluation. Patient’s Concern: A 29-year-old male patient who had suffered from COVID-19 eight weeks earlier, presented with an acute onset of breathlessness and right-sided chest pain due to pneumothorax. Emergency tube thoracostomy was performed. However, it failed to improve hypoxia. Diagnosis: High-resolution computed tomography of the thorax with computed tomography pulmonary angiography revealed pulmonary arterial thrombosis, ground-glass opacities, and bilateral pneumatoceles. Interventions: Hospital admission and treatment with low molecular weight heparin at a dose of 1.5 mg/kg every 24 h. Outcomes: The large pneumatocele showed significant resolution after three months of follow-ups. Lessons: Being increasingly reported after having a SARS-CoV-2 infection, pneumatocele formation, due to post-COVID lung scarring and late vascular thrombotic events, is a peculiar sequela and can present as acute dyspnoea. Long-term preventive anticoagulants after recovery from COVID-19 are necessary. Breathing exercises during recovery should be done with caution.

A Potentially Disastrous Life -Threatening Complication of Emergency Tube Thoracostomy in A Simple Case of Spontaneous Pneumothorax

Emergency tube thoracostomy carries risks of infective and technical complications. The aseptic technique is essential to prevent infections, while blunt dissection method can minimise the associated technical complications. Preparation and adherence to protocols as well as appropriate knowledge and skills, however, are of utmost importance to reduce risks of complications. Physicians must have adequate knowledge of anatomy and the procedure to ensure for accurate site tube placement without any complication. This case illustrates how a failure to appropriately use the instrument resulted in a displaced scalpel blade inside the thoracic cavity. It caused an unnecessary thoracotomy for blade retrieval. The mishap escalated a simple procedure to the potentially disastrous life-threatening event.

Association of Prehospital Needle Decompression With Mortality Among Injured Patients Requiring Emergency Chest Decompression

Prehospital needle decompression (PHND) is a rare but potentially life-saving procedure. Prior studies on chest decompression in trauma patients have been small, limited to single institutions or emergency medical services (EMS) agencies, and lacked appropriate comparator groups, making the effectiveness of this intervention uncertain. To determine the association of PHND with early mortality in patients requiring emergent chest decompression. This was a retrospective cohort study conducted from January 1, 2000, to March 18, 2020, using the Pennsylvania Trauma Outcomes Study database. Patients older than 15 years who were transported from the scene of injury were included in the analysis. Data were analyzed between April 28, 2021, and September 18, 2021. Patients without PHND but undergoing tube thoracostomy within 15 minutes of arrival at the trauma center were the comparison group that may have benefited from PHND. Mixed-effect logistic regression was used to determine the variability in PHND between patient and EMS agency factors, as well as the association between risk-adjusted 24-hour mortality and PHND, accounting for clustering by center and year. Propensity score matching, instrumental variable analysis using EMS agency-level PHND proportion, and several sensitivity analyses were performed to address potential bias. A total of 8469 patients were included in this study; 1337 patients (11%) had PHND (median [IQR] age, 37 [25-52] years; 1096 male patients [82.0%]), and 7132 patients (84.2%) had emergent tube thoracostomy (median [IQR] age, 32 [23-48] years; 6083 male patients [85.3%]). PHND rates were stable over the study period between 0.2% and 0.5%. Patient factors accounted for 43% of the variation in PHND rates, whereas EMS agency accounted for 57% of the variation. PHND was associated with a 25% decrease in odds of 24-hour mortality (odds ratio [OR], 0.75; 95% CI, 0.61-0.94; P = .01). Similar results were found in patients who survived their ED stay (OR, 0.68; 95% CI, 0.52-0.89; P < .01), excluding severe traumatic brain injury (OR, 0.65; 95% CI, 0.45-0.95; P = .03), and restricted to patients with severe chest injury (OR, 0.72; 95% CI, 0.55-0.93; P = .01). PHND was also associated with lower odds of 24-hour mortality after propensity matching (OR, 0.79; 95% CI, 0.62-0.98; P = .04) when restricting matches to the same EMS agency (OR, 0.74; 95% CI, 0.56-0.99; P = .04) and in instrumental variable probit regression (coefficient, -0.60; 95% CI, -1.04 to -0.16; P < .01). In this cohort study, PHND was associated with lower 24-hour mortality compared with emergent trauma center chest tube placement in trauma patients. Although performed rarely, PHND can be a life-saving intervention and should be reinforced in EMS education for appropriately selected trauma patients.

Electrocardiographic manifestations in a large right-sided pneumothorax

BackgroundPneumothorax is an extrapulmonary air accumulation within the pleural space between the lung and chest wall. Once pneumothorax acquires tension physiology, it turns into a potentially lethal condition requiring prompt surgical intervention. Common symptoms are chest pain and dyspnea; hence an electrocardiogram (ECG) is often performed in emergent settings. However, early diagnosis of pneumothorax remains challenging since chest pain and dyspnea are common symptomatology in various life-threatening emergencies, often leading to overlooked or delayed diagnosis. While the majority of left-sided pneumothorax-related ECG abnormalities have been reported, right-sided pneumothorax-related ECG abnormalities remain elucidated.Case presentationA 51-year-old man presented to the emergency department with acute-onset chest pain and dyspnea. Upon initial examination, the patient had a blood pressure of 98/68 mmHg, tachycardia of 100 beats/min, tachypnea of 28 breaths/min, and oxygen saturation of 94% on ambient air. Chest auscultation revealed decreased breath sounds on the right side. ECG revealed sinus tachycardia, phasic voltage variation of QRS complexes in V4–6, P-pulmonale, and vertical P-wave axis. Chest radiographs and computed tomography (CT) scans confirmed a large right-sided pneumothorax. The patient’s symptoms, all the ECG abnormalities, and increased heart rate on the initial presentation resolved following an emergent tube thoracostomy. Moreover, we found that these ECG abnormalities consisted of two independent factors: respiratory components and the diaphragm level. Besides, CT scans demonstrated the large bullae with a maximum diameter of 46 × 49 mm in the right lung apex. Finally, the patient showed complete recovery with a thoracoscopic bullectomy.ConclusionsHerein, we describe a case of a large right-sided primary spontaneous pneumothorax with characteristic ECG findings that resolved following re-expansion of the lung. Our case may shed new light on the mechanisms underlying ECG abnormalities associated with a large right-sided pneumothorax. Moreover, ECG manifestations may provide useful information to suspect a large pneumothorax or tension pneumothorax in emergent settings where ECGs are performed on patients with acute chest pain and dyspnea.

An Unusual Case of Tension Hydrothorax in a Pediatric Patient

A 2-year-old ill-appearing boy presented to the emergency department (ED). His vital signs indicated sepsis (temperature of 38.6°C, blood pressure 79/45 mm Hg, a heart rate of 189 beats/min, and oxygen saturation 85% on room air). A chest radiograph revealed a large left-sided pleural effusion with mediastinal shift (Figure 1). Emergent tube thoracostomy was performed, which drained several hundred milliliters of muddy brown output and immediately improved his vital signs. Parenteral antibiotics were administered in the pediatric intensive care unit, and the patient showed dramatic clinical improvement over 48 hours. While drinking pink soda, a nurse noticed that his chest tube output immediately turned the same color (Figure 2). Further history revealed that he had swallowed a coin 2 days before his visit to the ED. Several unsuccessful endoscopic attempts at removal had been performed at another hospital. He had ultimately been discharged with instructions to drink a lot of water to pass the coin. Figure 2Thoracostomy output draining pink fluid. View Large Image Figure Viewer Download Hi-res image

Differentiate pleural effusion from hemothorax after blunt chest trauma; comparison of computed tomography attenuation values

Abstract Background/Purpose Hemothorax should be suspected in any patient with blunt chest trauma. However, not every fluid detected by ultrasound or computed tomography (CT) is a hemothorax, especially in elderlies and multi-morbid patients. To avoid unnecessary emergent tube thoracostomy, we have to make the differentiation in a time fashion. Purpose To assess the applicability of the CT attenuation value in differentiating hemothorax from pleural effusions. Methods In this retrospective study, we identified patients who underwent chest CT during a 39-month period. Patients with definitive diagnoses of hemothorax, pleural effusion, and empyema were enrolled. We selected the 3 non-enhanced CT scan slices containing the largest amount of fluid to measure the Hounsfield unit (HU) values of the pleural fluid, and those of the aortic blood. The HU value ratios of the pleural fluid over aortic blood (P/A) were calculated. We compared the HU and P/A values between the patient groups. Receiver operating characteristic (ROC) curves were constructed to determine the validity and cutoff values. Results Hemothorax had significantly higher attenuation values and P/A ratios than did pleural effusion or empyema (P Conclusions CT attenuation values and P/A ratios are distinguishable between hemothorax, pleural effusion, and empyema.

Woman With Severe Dyspnea

A 20-year-old Micronesian woman presented to the emergency department with dyspnea, fever, hypoxia, hypotension, and absent breath sounds over the left side of the thorax. Chest radiograph (Figures 1 and 2) showed a left tension hydrothorax requiring emergency tube thoracostomy. Two liters of serous fluid were drained from the pleural cavity.

A shocking complication of a pneumothorax: chest tube-induced arrhythmias and review of the literature.

We describe a patient with a recent chest tube insertion leading to atrial fibrillation with rapid ventricular rate that led to multiple inappropriate internal cardiac defibrillator (ICD) shocks. This is the first reported case of this occurring in a patient with an ICD leading to inappropriate shocks. Our elderly patient with emphysema presented with a spontaneous pneumothorax and developed rapid atrial fibrillation following emergency tube thoracostomy. The patient had a single lead ICD and received multiple inappropriate shocks for the rapid ventricular rate in the therapy zone. Although medical treatment helped stabilize the patient, resolution of the atrial fibrillation occurred only after the chest tube was removed. In a patient with a chest tube or other intrathoracic catheters, maintaining a high index of suspicion that chest tube insertions can cause secondary life threatening cardiovascular complications needs to be considered. In such patients, removal of the device proves to be the most prudent treatment action.

Spontaneous Pnemoperitoneum after Blunt Trauma Chest –Diagnostic Dilemma-Role of Diagnostic Laparoscopy – Case Report

Introduction: Pneumoperitoneum is a striking feature of hollow viscous perforation and may need of immediate surgical intervention. Blunt trauma chest with pneumoperitoneum without evidence of hollow viscous perforation is unusual and the condition is called spotaneous pneumoperitoneum. Case Presentation: A 29 year male presented to the emergency department after a road traffic accident with hypotension and respiratory distress. Clinically there was surgical emphysema associated with diminished breath sound over left half of the chest and multiple contusions over left hypochondrium and left flank. Bedside X- ray showed fracture of ribs on left side with pneumothorax and air under both the dome of diaphragm. Emergency tube thoracostomy done and respiratory symptoms improved. Further patient evaluated with Ultrasound abdomen and Computerized tomogram of abdomen. Dilated bowels, gross pneumoperitoneum with minimal fluid collection was noted. Diagnostic laparoscopy done to find out hollow viscous perforation or diaphragm injury but to the surprising hollow viscous and diaphragm found to be normal. Case Discussion: Pneumothorax and pnemoperitoneum with presence of abdominal contusions make the surgeon in dilemma for choosing conservative or therapeutic approach. Conclusion: Diagnostic laparoscopy with systemic exploration of abdominal organs and spaces will help in diagnosis and mandatory laparotomy may avoided.

Pulmonary cystic lesions post motor vehicle accident: a rare occurrence

A 24-year-old man was brought to our institution after a high-speed motor vehicle collision, where he was an unrestrained passenger. The patient initially was in respiratory distress requiring intubation. A chest X-ray (Figure 1A) revealed a left tension pneumothorax and increased alveolar densities bilaterally suggestive of pulmonary contusion. After emergent tube thoracostomy, repeat chest X-ray showed resolution of the pneumothorax with evidence of cystic lesions in the left lung (Figure 1B). A computed tomography (CT) scan of the chest revealed multiple …

Diagnostic Approach to Pulmonary Nodules in the Postpneumonectomy Patient

P CHALLENGE The postpneumonectomy patient with an indeterminate pulmonary nodule in the contralateral lung represents a formidable diagnostic and therapeutic challenge. The diagnosis of suspicious peripheral lung nodules is performed most commonly by computed tomography (CT)–guided transthoracic needle aspiration (TTNA). Depending on the size and location, the diagnostic accuracy of TTNA ranges from 65%-96%.1 The TTNA-associated risk of pneumothorax, particularly in patients with emphysema, is 21%-40%, depending on the number of needle passes and the experience of the operator.2,3 Many interventional radiologists consider a previous pneumonectomy as a contraindication to TTNA because of the significant risk of pneumothorax. In one published report, TTNA in postpeumonectomy patients was performed with a thoracic surgeon directly standing by for potential emergent tube thoracostomy.4 We propose a safe diagnostic technique with therapeutic potential for postpeumonectomy patients with indeterminate pulmonary nodules.

The Emergent Tube Thoracostomy

This instructional video demonstrates the performance of the emergent tube thoracostomy (Figure 1). The video was filmed at the Evanston Northwestern Healthcare Simulation Center (<link removed as it refers to this location>). The procedure was performed on the TraumaMan system (Simulab Corporation, Seattle, WA; http://www.simulab.com/). We have created a series of videos to instruct our residents on a variety of emergent life-saving procedures using a variety of high-fidelity simulators and host these videos on a Web site for the Northwestern emergency medicine residents to access and review. Emergent tube thoracostomy. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Tension Chylothorax

Thoracic duct injury resulting in chylothorax is a well-known and documented complication of thoracic surgery. However, chylothorax under tension is a rarely reported complication that results in respiratory and hemodynamic collapse. Early recognition and treatment of this entity are essential for optimal patient outcome. Herein we present two cases of postoperative tension chylothorax followed by a review of the diagnostic work-up and therapy for this complication.

Diagnosis of malpositioned chest tubes after emergency tube thoracostomy: Is computed tomography more accurate than chest radiograph?

Objective The aim of this study was to compare the accuracy between computed tomography (CT) and frontal chest radiography in the diagnosis of malpositioned chest tubes (MCT). Materials and methods CT scans positive for MCT between March 2000 and March 2004 were reviewed. Two radiologists assessed for intra- and extrathoracic locations of MCT in CT studies. Two physicians who were blinded to the results of CT scans assessed the frontal chest radiographs for location of chest tubes, within the pleural space or outside pleural space. The results of CT were then compared with the results of frontal chest radiographs. Medical records were also reviewed for function of the chest tubes and any complications induced by MCT. Results CT revealed 28 MCT among the 76 chest tubes that were placed in 54 patients. Among the 28 MCT detected by CT, 23 tubes were in the intrathoracic location (20 intraparenchymal; 3 intrafissural) and 5 tubes were in the extrathoracic location (4 in mediastinum; 1 in chest wall). Frontal chest radiographs only revealed six MCT. Among 28 MCT, 16 sufficient, 8 insufficient, and 4 indeterminate functions of the chest tubes were noted from medical charts. One patient complicated with lung abscess, four patients had suffered pleural empyema, and one patient suffered active lung parenchymal bleeding, resulting from MCT. Conclusions CT is more accurate than chest radiograph for the diagnosis of MCT. For selected patients with inadequacy drainage of the tubes and when chest radiograph is noncontributory, CT scan is recommended to clarify the exact location of chest tubes.

Trauma torácico: fatores de risco de complicações pleuropulmonares pós-drenagem pleural fechada

O objetivo do presente estudo foi avaliar a importância dos fatores de risco na gênese das complicações pleuropulmonares, pós-drenagem pleural fechada. Analisou-se, prospectivamente, no período de janeiro de 1998 a junho de 1999, um total de 167 pacientes submetidos à drenagem pleural fechada, sendo estratificados em dois grupos selecionados para um estudo de acompanhamento de coortes. Ao grupo controle, de 104 pacientes, não foi administrada antibioticoterapia e, no grupo experimental, de 63 pacientes, a cefalotina foi a droga utilizada. A idade no grupo-controle variou entre 13 e 53 anos (26,8±8,9) e no grupo experimental entre 15 e 57 (24,9±7,9), predominando o sexo masculino (95,2%), nos dois grupos estudados. O trauma aberto incidiu em 92,8% dos pacientes, com predominância para as feridas por arma branca em 58,7%, contra 24,6% de feridas por projétil de arma de fogo. As complicações pleuropulmonares estiveram presentes em 35 pacientes (33,78%) do grupo controle, ao passo que, no grupo experimental, apenas 18 (28,6%) evoluíram com este tipo de complicação. Não ocorreram óbitos em ambas as séries estudadas. Nas análises estatísticas, o modelo bivariado mostrou que o tipo de trauma e o tempo de drenagem pleural foram as variáveis que mais importância tiveram como fatores preditivos de complicações. Na análise de regressão logística multivariada, as variáveis tempo de internação, trauma fechado e volume de sangue drenado maior do que 500ml, quando associadas, influenciaram de maneira positiva a ocorrência de complicações.

Chest tube decompression of blunt chest injuries by physicians in the field: effectiveness and complications.

Recent literature suggests that patients who undergo emergent tube thoracostomy in the field are at increased risks for complications. This study evaluates indications, complications, and effectiveness of field placement of chest tubes by an aeromedical service. In a prospective study, 624 consecutive patients with chest injuries (Abbreviated Injury Scale score 1-6) were included. All patients were treated at the scene by a physician-staffed aeromedical service and transported by air to a Level I trauma center. Indications, clinical findings before and after chest tube insertion, and subsequent radiologic diagnosis by chest roentgenography were documented prospectively. Seventy-six chest tubes (50 unilateral, 13 bilateral) were inserted laterally in 63 patients (10%) by blunt dissection. Clinical findings included pneumothorax in 30 patients and hemothorax in 18 patients. In 15 patients receiving field chest tubes, neither pneumothorax nor hemothorax was confirmed. Six patients (<1%) arrived at the trauma center with unsuspected pneumothoraces and required chest tube insertion. No tension pneumothoraces escaped field detection and treatment. Four chest tubes placed in the field required repositioning in the hospital because of malfunction or malpositioning. Radiologic findings excluded intraparenchymal tube placements in all patients. No pleural infections were observed in these 63 patients during their hospital stay. No antibiotics were administered as a result of prehospital chest tube placement. Prehospital chest tube thoracostomy is safe, effective, and associated with low morbidity. Nontherapeutic chest tube placements occurred in 15 of 624 patients (2.4%); missed pneumothoraces occurred in 6 of 624 patients (<1%). Aggressive prehospital physician management of blunt chest trauma leads to an earlier treatment of potentially life-threatening injuries. Significant morbidity can be avoided by prompt pleural decompression using proper techniques.

Complications after emergency tube thoracostomy: Assessment with CT: Baldt MM, Bankier AA, Germann PS. Radiology. 1995;195: 539-43

Complications after emergency tube thoracostomy: Assessment with CT: Baldt MM, Bankier AA, Germann PS. Radiology. 1995;195: 539-43

Complications after emergency tube thoracostomy: assessment with CT.

Complications after emergency tube thoracostomy: assessment with CT.

Complications after emergency tube thoracostomy: assessment with CT.

To assess the spectrum of complications after emergency tube thoracostomy (TT) and show the role of computed tomography (CT) in detection of these abnormalities. CT scans, chest radiographs, and clinical data were reviewed in 51 patients (77 tubes) who underwent emergency TT after trauma. CT scans were analyzed for chest tube malposition (CTM) and persistent pneumo- or hemathoraces. The complication most often seen after emergency TT, as demonstrated with CT, was CTM (20 of 77 tubes [26%]). Only seven of the CTMs seen at CT were evident on chest radiographs. Two extrathoracic and 18 intrathoracic (five intraparenchymal, nine intrafissural) malpositioned tubes were seen at CT. Other findings included persistent pneumo-and hemathoraces in 16 patients. Patients undergoing emergency TT are at increased risk for complications. CTM is the most common abnormality and should be diagnosed promptly to prevent additional problems. CT is more useful than plain radiography for establishing a diagnosis.