Intercostal Chest Drain Insertion Research Articles

Spontaneous pneumothorax in metastatic osteosarcoma: a case series

BackgroundMalignancy-associated secondary spontaneous pneumothorax (MSSP) has an incidence of 1% with a risk for recurrence of 9.4% reported in association with sarcomas, histiocytoma, malignant thymoma, and cancers of the breast and thyroid.Case presentationWe report a series of four patients who presented to us with MSSP associated with pulmonary metastasis of osteosarcoma, all four being young males with metastasis to the lungs. All four patients were non-smokers and had no family history of malignancy. Less than 2% of all spontaneous pneumothoraxes present with bilateral pneumothorax, and our series reports the same in three patients. The occurrence of pneumothorax in two of the patients was in the week following chemotherapy. As there was evidence of pulmonary metastasis in these patients along with the clinical presentation of pneumothorax following chemotherapy, tumor necrosis was considered the likely etiology of spontaneous pneumothorax in these patients. All four patients required intercostal chest drain insertion, and the ICD tubes had to be retained for a prolonged duration due to either persistent air leak or secondary infection. ICD tube insertion further compromised the poor mobility of patients with lower limb lesions due to increased pain and was detrimental to the emotional morale of the patient and caregivers. The 2-year survival in such patients with pneumothorax is less than 10%.ConclusionsOur series highlights the need for respiratory evaluation and follow-up both clinically and radiologically in cases of osteosarcoma, especially in the immediate post-chemotherapy period.

Fatal misadventure of trocariatrogenic right atrial perforation during tube thoracostomy in a patient with cardiomegaly: a case report and review of literature

Background: Tube thoracostomy is a routine life-saving procedure with vast implications in the management of various thoracic conditions that include pleural effusion, pneumothorax, empyema, blunt, and penetrating thoracic trauma. Though a simple procedure, a high rate of morbidity and mortality is associated if a complication occurs. Case Presentation: An intercostal chest tube was inserted by trocar method in a 47-year-old female with rheumatic heart disease associated cardiomegaly, which resulted in right atrial perforation. The patient was managed successfully by an emergency thoracotomy followed by cardiac repair surgery. Our case report demonstrates a very unusual yet life-threatening complication of a simple intervention such as intercostal chest tube insertion and highlights the management of the same. Aim of this case report is to discuss the clinical implications and literature pertaining to the iatrogenic cardiac injury during tube thoracostomy. Conclusion: The use of the blind method of intercostal chest drain insertion using a trocar should be discouraged, particularly in cases with dense pleural adhesions or cardiomegaly.

Approach to malignant pleural effusions: Role of pleural manometry exemplified by case scenarios.

Issues related to the management of pleural effusion in India are unique. With high incidence of tuberculosis and malignancy, managing patients with pleural effusion may not be the same between patients. Decisions on intercostal chest drain insertion, volume of fluid to be removed during therapeutic thoracentesis, and further diagnostic imaging and investigations are often taken with difficulty in low-resource settings. Pleural manometry can help resolve these issues and help in the management of such patients. Pleural manometry has been advocated as a valuable tool to characterize underlying lung behavior during thoracentesis and has been proposed to be useful in diagnosing unexpandable lung, predicting the success of pleurodesis, and preventing the development of excessively negative pleural pressures which in turn may lead to the development of reexpansion pulmonary edema. There is very little literature on pleural manometry from India and other developing countries. In this article, the utility of pleural manometry in managing patients with malignant pleural effusion is discussed.

Right congenital diaphragmatic hernia: Four cases and literature review

Background: Left-sided Bochdalek congenital diaphragmatic hernia (CDH) is the most common type of CDH. The right-sided Bochdalek CDH is rare and usually contains only the liver as its content. We describe four children with right CDH managed at our institution over 3 years. Materials and Methods: We present a retrospective analysis of four patients with right CDH managed at our institution from 2012 to 2015 with respect to age at presentation, sex, presenting symptoms, investigations, associated anomalies, management, and outcome. Results: The average age at presentation was 1.5 years, with range being 5 days to 4 years. The three older children presented with a history of frequent respiratory tract infections. The neonate was a preterm low-birth weight baby and had respiratory distress since birth. A chest radiograph suggested right pneumothorax for which intercostal chest drain insertion was done. A repeat chest X-ray showed suspicion of right-sided CDH which was confirmed on computerized tomography. All four patients underwent right thoracotomy with repair of the CDH. The neonate expired on the 4th postoperative day. The other three children had an uneventful postoperative recovery. Conclusion: Right-sided CDH is rare and has varied presentations and poorer outcome.

The modified ‘Jo'burg’ technique for securing intercostal chest drains

Insertion of an intercostal chest drain (ICD) is a common intervention in the management of either blunt or penetrating thoracic trauma. It is frequently performed by junior medical personnel as...

Supracostal percutaneous nephrolithotomy: A prospective comparative study.

Introduction:A widely prevalent fear of thoracic complications with the supracostal approach has led to its underutilization in percutaneous nephrolithotomy (PCNL). We frequently use the supracostal approach and compared the efficacy and thoracic complications of infracostal, supra 12th, and supra 11th punctures.Materials and Methods:This was a prospective study of patients who underwent PCNL between January 2005 and December 2012. The patients were divided into three groups based on the access: infracostal, supra 12th (between the 11th and 12th ribs) and supra 11th (between the 10th and 11th ribs). Clearance rates, fall in hemoglobin levels, transfusion rates, perioperative analgesic requirements, hospital stay and thoracic complications were compared.Results:Seven hundred patients were included for analysis. There were 179 (25.5%) patients in the supra 11th group, 187 (26.7%) patients in the supra 12th group and 334 (47.8%) patients in the infracostal group. The overall clearance rate was 78% with no difference in the three groups. The postoperative analgesic requirements were significantly higher in the supracostal groups and showed a graded increase from infracostal to supra 12th to supra 11th. During the study period, only 2 patients required angioembolization (0.3%) and none required open exploration. The number of patients requiring intercostal chest drain insertion was extremely low, at 1.6% and 2.2% in the supra 12th and supra 11th groups, respectively.Conclusions:Our results confirm the feasibility of the supracostal approach including punctures above the 11th rib, albeit at the cost of an increase in thoracic complications. Staying in the line of the calyx has helped us to minimize the most dreaded complication of bleeding requiring angioembolization.

Intercostal chest drain insertion by general physicians: attitudes, experience and implications for training, service and patient safety

BackgroundIntercostal chest drain (ICD) insertion is considered a core skill for the general physician. Recent guidelines have highlighted the risks of this procedure, while UK medical trainees have reported a...

Correlation Between ATLS Training and Junior Doctors’ Anatomical Knowledge of Intercostal Chest Drain Insertion

To review the ability of junior doctors (JDs) in identifying the correct anatomical site for intercostal chest drain insertion and whether prior Advanced Trauma Life Support (ATLS) training influences this. We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact preferred site for intercostal chest drain insertion. This study was conducted in a large metropolitan university hospital in South Africa. A total of 152 JDs participated in the study. Among them, 63 (41%) were men, and the mean age was 24 years. There were 90 (59%) PGY1 doctors and 62 (41%) PGY2 doctors. Overall, 28% (42/152) of all JDs correctly identified the site that was located within the accepted safe triangle. A significantly higher proportion of PGY2 doctors selected the correct site when compared with PGY1 doctors (39% vs 20%, p = 0.026). Those who had prior ATLS provider training were 6.8 times more likely to be able to identify the correct site (RR = 6.8, 95% CI: 3.7-12.5). Most of the JDs do not have sufficient anatomical knowledge to identify the safe insertion site for intercostal chest drain. Those who had undergone ATLS training were more likely to be able to identify the safe insertion site.

Noninterventional statistical comparison of BTS and CHEST guidelines for size and severity in primary pneumothorax

Hilar rather than apical interpleural distance more accurately predicts need for intercostal chest drain insertion http://ow.ly/JvKFY

Open pneumothorax: the spectrum and outcome of management based on Advanced Trauma Life Support recommendations.

The current management of open pneumothorax (OPTX) is based on Advanced Trauma Life Support (ATLS) recommendations and consists of the application of a three-way occlusive dressing, followed by intercostal chest drain insertion. Very little is known regarding the spectrum and outcome of this approach, especially in the civilian setting. We conducted a retrospective review of 58 consecutive patients with OPTX over a four-year period managed in a high volume metropolitan trauma service in South Africa. Of the 58 patients included, 95% (55/58) were male, and the mean age for all patients was 21 years. Ninety-seven percent of all injuries were inflicted by knives and the remaining 3% (2/58) of injuries were inflicted by unknown weapons. 59% of injuries were left sided. In six patients (10%) a protocol violation was present in their management. Five of the six patients (83%) in whom protocol violation occurred developed a life-threatening event (tension PTX) compared to none amongst those where the protocol was followed (p < 0.001). There was no mortality as a direct result of management of OPTX following ATLS recommendations. ATLS recommendations for OPTX are safe and effective. Any deviation from this standard practice is associated with avoidable morbidity and potential mortality.

P111 Procedural Experience, Training Opportunities And Attitudes Towards Intercostal Chest Drain Insertion: Variations Between Consultants, Trainees And Medical Sub-specialties

Background and method Intercostal chest drain (ICD) insertion has long been considered a core skill for the general physician to master. The NPSA alert in 2008 highlighted potential hazards associated with this procedure, whilst recent guidelines 1 advocate the use of thoracic ultrasound to reduce complications. These developments have occurred at a time when trainees report a growing lack of confidence in their clinical experience and procedural capabilities, alongside a decline in training opportunities 2 that might address the latter concern. Nonetheless, competence in ICD insertion remains a compulsory or highly desirable procedural skill to acquire on a number of UK specialty training curricula including that for general (internal) medicine. We carried out a survey of consultants and trainees who contribute to general medical services in hospitals across the Thames Valley region. This survey assessed factors including physicians’ attitudes towards ICD insertion; prior and recent procedural experience; training opportunities; and clinical knowledge. Results 90 clinicians (26 consultants; 41 registrars (ST3+); 23 core medical trainees (CT1/2)) responded to the survey. Most clinicians (94% of responses) felt that placing >5 ICDs was necessary to attain initial competence at the procedure; before continuing to place >5 ICDs on an annual basis in order to maintain that competence (78% of responses). However, only 17% of medical registrars surveyed reached this basic combined standard. Other key findings are summarised in Table 1. Conclusion Our findings demonstrate a disparity between clinical reality and the expectations junior doctors and consultants have of the physician in training with regards to ICD competence. Most trainees cannot achieve the number of procedures they feel are required to attain independence, nor maintain that independence on an annual basis; whilst access to training in thoracic ultrasound is limited outside certain specialties. This inexperience is manifest in variable clinical understanding and procedural confidence. Consideration needs to be given as to how medical training programmes might address these issues, and whether ICD insertion is even a skill that all general physicians can maintain competence in performing in the modern clinical environment. References Thorax 2010;65 Suppl 2:ii61–76 Clin Med 2013;13(5):434–9

P177 Patient-related Outcome Measurements In Pleural Effusions

Introduction Pleural disease is a common health problem in the general population and the number of pleural interventions available to physicians is rapidly expanding. Most clinical studies to date have focused on the generation of successful treatments for pleural diseases without considering patient-centred assessments of symptomatic relief in a procedure undertaken for patient benefit. Patient-related outcome measures (PROMs) such as the assessment of pain and difference in dyspnoea have been used in other disease areas to estimate effectiveness and guide interventions. This prospective study measured PROMs after pleural interventions using a specific survey questionnaire. Methods Data were collected from 95 patients treated in a tertiary referral centre from December 2013 to June 2014. Pleural interventions included diagnostic aspiration, therapeutic aspiration, thoracoscopy, intercostal chest drain insertion and indwelling pleural catheter insertion. We gathered information on pain, dyspnoea, expected improvement and willingness to repeat the procedure if needed using a 100 mm visual analogue scale (VAS). Clinical, radiological and histological data were recorded and categorised the patients with pleural effusions to either: malignant, infected, heart failure and undiagnosed. Patients with pneumothorax were classified to either primary or secondary. Data are presented as mean ± SD. Results Data were collected from 31 therapeutic aspirations, 30 intercostal drain insertions, 17 diagnostic/simple aspirations, 14 thoracoscopies and 3 indwelling catheter insertions. The results showed the procedure associated with the most pain is medical thoracoscopy (VAS: 20 ± 20.3 mms) whereas diagnostic aspiration (VAS: 2.52 ± 4.78 mms) was the least uncomfortable. Pain measurements were similar in intercostal and indwelling pleural catheter insertion groups (p: 0.75). VAS score for dyspnoea demonstrated that intercostal drain insertion had the greatest effect on patients’ breathlessness compared to the other procedures (VAS difference pre and post-procedure: 50.8 ± 27 mms).99.8% of the patients would repeat any of the pleural procedures if needed. Conclusion Our study, the first to prospectively assess patient-related outcomes in pleural procedures, demonstrates that different pleural procedures significantly improve symptoms alongside a high degree of patient satisfaction. Pleural PROMs may represent a standardised way of measuring symptomatic benefit which can be used in both clinical practice and future research.

An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa.

Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity. This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013. A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male. The median patient age was 24 years (interquartile range [IQR]: 20-29 years). There were 962 patients with unilateral ICDs and 44 with bilateral ICDs. Seventy-five per cent (758/1,006) sustained penetrating trauma and the remaining 25% (248/1006) sustained blunt trauma. Indications for ICD insertion were: haemopneumothorax (n=338), haemothorax (n=314), simple pneumothorax (n=265), tension pneumothorax (n=79) and open pneumothorax (n=54). Overall, 203 ICDs (19%) were associated with complications: 18% (36/203) were kinked, 18% (36/203) were inserted subcutaneously, 13% (27/203) were too shallow and in 7% (14/203) there was inadequate fixation resulting in dislodgement. Four patients (2%) sustained visceral injuries and two sustained vascular injuries. Forty-one per cent (83/203) were inserted outside the 'triangle of safety' but without visceral or vascular injuries. One patient had the ICD inserted on the wrong side. Junior doctors inserted 798 ICDs (76%) while senior doctors inserted 252 (24%). Junior doctors had a significantly higher complication rate (24%) compared with senior doctors (5%) (p<0.001). There was no mortality as a direct result of ICD insertion. </sec> Conclusions ICD insertion is associated with a high rate of complications. These complications are significantly higher when junior doctors perform the procedure. A multifaceted quality improvement programme is needed to improve the situation.

Cadaveric simulation in surgical training: A high-fidelity model to increase trainee confidence

Cadaveric simulation in surgical training: A high-fidelity model to increase trainee confidence

S82 Multi-centre prospective comparison of the BTS and ACCP guidelines to determine size in primary spontaneous pneumothorax

Introduction and ObjectivesAttempts to develop standardised guidelines in the management of primary spontaneous pneumothorax (PSP) have been severely hampered by a lack of high quality clinical research. The American College...

P72 In the Post Ultrasound Era, are Core Medical Trainees Struggling to get Experience in Chest Drain Insertion?

IntroductionIn the UK, upon completion of Core Medical Training (CMT), procedural independence is expected for pneumothorax drains and is desirable for pleural effusions. In 2009, prompted by a National Patient...

P122 The Use of Thoracic Ultrasound in Management of Patients with Pleural Disorders

IntroductionPleural diseases are common reason for referral to respiratory specialists. Thoracic ultrasound has become an important tool for investigation and management of patients with pleural diseases. Thoracic ultrasound allows real-time...

Survey of major complications of intercostal chest drain insertion in the UK

BackgroundFollowing reports from the National Patient Safety Agency of deaths and serious harm from intercostal chest drains (ICD) we conducted a national survey among chest physicians of their experience of...

INTERCOSTAL CHEST DRAIN (ICD) INSERTION: METHODS AND PITFALLS AND OUTCOMES IN 52 PATIENTS WITH PLEURAL DISEASES

INTERCOSTAL CHEST DRAIN (ICD) INSERTION: METHODS AND PITFALLS AND OUTCOMES IN 52 PATIENTS WITH PLEURAL DISEASES

Secondary spontaneous pneumothorax: indication for intercostal chest drain insertion?

A patient with chronic obstructive pulmonary disease presented with a history of sudden onset breathlessness and the chest radiograph shown in fig 1. Current guidelines advocate insertion of an intercostal chest drain for …