Loculated Pneumothorax Research Articles

Large Pulmonary Bullae, Resulting from Tuberculosis, in the Context of Extensive Pneumothorax Caused by a Penetrating Chest Wound

Pulmonary bullae typically occur either idiopathically or in the context of chronic obstructive pulmonary disease and pulmonary infections. Clinical manifestations of pulmonary bullae include cough, shortness of breath, and chest pain. In some cases, they may be asymptomatic. Differentiating between pneumothorax and pulmonary bullae can be challenging when they coexist. Therefore, obtaining a detailed patient history, conducting a physical examination, performing laboratory tests, and utilizing radiology studies are essential diagnostic tools that should be employed simultaneously. In this case report, we present a patient who developed a wide pneumothorax due to a penetrating chest wound caused by a knife. Initially, the large lung cavity, which had already formed due to tuberculosis, was misdiagnosed as a loculated pneumothorax.

Trans-fissure and trans-lobar coil insertion technique for small lesions positioned inside the fissure.

The objective of this study is to present a technique of localization of difficult-to-locate lesions inside the fissure by deploying a coil with one of its ends left inside the fissure, and also, to evaluate the safety and the efficiency of this localization technique. Ten (10) patients with lesions in the fissure were identified during discussion at the multidisciplinary team meeting (MDT) and were recruited in the study. Attending surgeons verified that the lesions were unable to be located with minimally invasive approaches. These patients underwent localization of their lesion/s inside the fissure with a coil which was inserted through an adjacent lobe, through the fissure and inside the lesion with the other end protruding inside the fissure. All patients were next subjected to resection of their lesions with minimally invasive approaches. All patients had their lesions resected (with wedge resection or segmentectomies) with adequate margins (R0 resection). No conversion to thoracotomy was necessitated to attempt to palpate the lesion. Small, localized pneumothorax was noted in 7 patients; whereas, all patients had small laceration of their lung parenchyma along the course of the needle without, however, any action needed for these sequalae. The presented technique offers precise localization which leads to successful and safe resection of difficult-to-locate lesions inside the fissure via minimally invasive approaches. The clinical implications of this technique are numerous and its utilization can augment the successful performance of minimally invasive techniques for lesions situated inside the fissure.

Loculated Pneumothorax in COVID-19 Patient – A Case Report

Aim: Loculated pneumothorax and multilocular cystic lung lesions are rare complications of acute respiratory distress syndrome in patients with COVID-19 infection. In this case report we wanted to emphasize that not only mechanically ventilated patients are at increased risk of pneumothorax and cystic lung lesions. Those lesions can also be found in non-ventilated patients. Case report: We present a case report of a 52-year-old man who was hospitalized because of COVID-19 pneumonia. MSCT pulmonary angiography revealed ground glass opacities, multilocular cystic lesions and loculated pneumothorax. On followup computerized tomography examination in an outpatient hospital two months later, there was a significant regression of the lung parenchymal ground glass opacities, as well as the regression of the cystic lesions with residual fluid-filled lesion in the oblique interlobar fissure. Conclusion: Only few case reports have been published on this specific lung pathology in COVID-19 disease. Increased incidence of complications such as pneumothorax in COVID-19 pneumonia is common, but physicians should also be aware of the possibility of other lung pathologies such as loculated pneumothorax and multilocular cystic lesions which can present not only in mechanically ventilated patients.

POSTERIOR PNEUMOTHORAX IN A PATIENT WITH COVID-19 ON ECMO: A CASE REPORT

TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: Pneumothoraces are a known complication of SARS-CoV-2, but the reported rate varies between studies. Posterior pneumothoraces are extremely uncommon with few published case reports. CASE PRESENTATION: A 51-year-old woman presented with dyspnea, fever, pulmonary infiltrates, and positive SARS-CoV2 nasopharyngeal PCR. Her respiratory status deteriorated, she was intubated, and she ultimately required VV-ECMO cannulation. Her hospital course was complicated by DVT, pulmonary aspergillosis, E coli pneumonia, and left sided hydropneumothorax treated with chest tube drainage. On hospital day 56, the patient abruptly developed a vasopressor requirement with a rapid elevation in lactate. CXR identified a large left air space. POCUS of the chest was remarkable for A-line artifact and absent lung sliding of the left posterior chest. CT confirmed a posterior pneumothorax. A 14Fr small-bore chest tube was placed by IR with improvement in the size of the pneumothorax and hemodynamic status, shown on image C below. The patient’s course was further complicated by right-sided hydropneumothorax due to E. coli and E. faecalis empyema that was treated with 14Fr chest tube drainage. She gradually improved, was decannulated from VV-ECMO, and on hospital day 107 was discharged to an acute rehabilitation facility with all chest tubes removed. DISCUSSION: Here we describe a patient’s hospital course complicated by repeated pneumothoraces including a left posterior loculated pneumothorax causing tension physiology. CONCLUSIONS: Available literature suggests pneumothorax may occur in 11% of COVID-19 patients treated with ECMO. The proper management of these patients is still unclear and clinicians must take these complications into account when directing care. DISCLOSURE: Nothing to declare. KEYWORD: Pneumothorax

Image-guided interventional radiological delivery of chimeric antigen receptor (CAR) T cells for pleural malignancies in a phase I/II clinical trial

ObjectivesWe describe techniques and results of image-guided delivery of mesothelin-targeted chimeric antigen receptor (CAR) T cells in patients with pleural malignancies in a phase I/II trial (ClinicalTrials.gov: NCT02414269). Materials and methodsPatients without a pleural catheter or who lack effusion for insertion of a catheter (31 of 41) were administered intrapleural CAR T cells by interventional radiologists under image guidance by computed tomography or ultrasound. CAR T cells were administered through a needle in an accessible pleural loculation (intracavitary) or following an induced loculated artificial pneumothorax. In patients where intracavitary infusion was not feasible, CAR T cells were injected via percutaneous approach either surrounding and/or in the pleural nodule/thickening (intratumoral). Pre- and post-procedural clinical, laboratory, and imaging findings were assessed. ResultsCAR T cells were administered intrapleurally in 31 patients (33 procedures, 2 patients were administered a second dose) with successful delivery of planned dose (10–186 mL); 14/33 (42%) intracavitary and 19/33 (58%) intratumoral. All procedures were completed within 2 h of T-cell thawing. There were no procedure-related adverse events greater than grade 1 (1 in 3 patients had prior ipsilateral pleural fusion procedures). The most common imaging finding was ground glass opacities with interlobular septal thickening and/or consolidation, observed in 12/33 (36%) procedures. There was no difference in the incidence of fever, CRP, IL-6, and peak vector copy number in the peripheral blood between infusion methods. ConclusionImage-guided intrapleural delivery of CAR T cells using intracavitary or intratumoral routes is feasible, repeatable and safe across anatomically variable pleural cancers.

BULLOUS LUNG DISEASE FOLLOWING COVID-19 INFECTION

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: The ongoing coronavirus disease 2019 (COVID-19) pandemic has resulted in persistent pulmonary complications among survivors. As our understanding of post infectious pulmonary phenomena continues to evolve, it is clear there are multiple difference manifestations of pulmonary lung disease associated with severe acute respiratory syndrome coronavirus 2 (SARS CoV-2). Here we describe a case of bullous lung disease as a complication of COVID-19. CASE PRESENTATION: A 61-year-old gentleman without significant past medical history presented with worsening shortness of breath of two days duration. Three months prior to presentation he was hospitalized for acute hypoxemic respiratory failure due to COVID-19 requiring Bi-level Positive Airway Pressure which was complicated by pneumomediastinum and right-sided pneumothorax that required chemical pleurodesis. On this presentation, he was hypoxemic and CT scan of the chest showed extensive bullous lung disease (BLD) throughout the right lung with mediastinal shift, not noted on prior imaging. He denied family history of lung disease or connective tissue disease. Prior to COVID-19 infection he was an avid marathon-runner, worked as a civil engineer with no occupational exposures, and never smoked tobacco products, vaped electronic cigarettes, or used illicit drugs. Admission vitals were unremarkable and physical exam revealed decreased breath sounds on the right side. His laboratory data including repeat SARS CoV-2 nasal polymerase chain reaction, alpha-1 antitrypsin and angiotensin-converting enzyme levels were unrevealing. Cardiothoracic surgery was consulted and he successfully underwent Video-Assisted Thoracoscopic surgery with wedge resection of the right lower lobe and chemical pleurodesis. Pathology ruled out a loculated pneumothorax and confirmed the presence of bullae localized within the lung parenchyma. DISCUSSION: Bullous lung disease has been described secondary to cocaine, cigarette or marijuana smoking as well as Emphysema, Sarcoidosis, alpha1-antitrypsin deficiency, Marfan's syndrome, Ehlers-Danlos syndrome and inhaled fiberglass exposure. However, our patient did not have any family history of lung disease, occupational exposures or smoking history, and physical exam was not suggestive of either Marfan's or Ehlers-Danlos syndrome. Since there was no underlying lung disease prior to hospitalization, common etiologies of bullous lung disease were ruled out, and given temporal association with COVID-19 infection, we hypothesized that his lung disease was related to his infection. Although the relationship between bullous lung disease and COVID-19 has yet-to-be defined, case reports have described this emerging association. CONCLUSIONS: Further investigation in the development of chronic lung disease following COVID-19 infection is sorely needed given the growing population of COVID-19 survivors. REFERENCE #1: Berhane S, Tabor A, Sahu A, Singh A. Development of bullous lung disease in a patient with severe COVID-19 pneumonitis. BMJ Case Reports. 2020;13(10):e237455. REFERENCE #2: Sun R, Liu H, Wang X. Mediastinal Emphysema, Giant Bulla, and Pneumothorax Developed during the Course of COVID-19 Pneumonia. Korean J Radiol. 2020;21(5):541-544. REFERENCE #3: Goldberg C, Carey KE. Bullous lung disease. West J Emerg Med. 2013;14(5):450-451. doi:10.5811/westjem.2013.3.16276. DISCLOSURES: No relevant relationships by Kwesi Amoah, source=Web Response No relevant relationships by robert homer, source=Web Response No relevant relationships by Denyse Lutchmansingh, source=Web Response No relevant relationships by Prachi Pednekar, source=Web Response No relevant relationships by Changwan Ryu, source=Web Response

CT-guided microcoil localization for pulmonary nodules in the scapula-shadowed area before Video-Assisted Thoracic Surgery.

To evaluate the feasibility and safety of CT-guided microcoil localization for pulmonary nodules in the scapula-shadowed area before video-assisted thoracic surgery (VATS). Forty-seven patients (18 males, 19 females; mean age 57.5 years) with 48 pulmonary nodules covered by the scapulae were consecutively enrolled in this study. Successful targeting, localization, and VATS were defined as implantation of microcoil at the target site on CT image obtained immediately after the marking procedure, visualization of nodule location during VATS, and complete resection of the target nodule with adequate margin, respectively. Meanwhile, the procedure-related complication rate was also recorded. The rates of successful targeting and localization were 95.8% (46/48) and 89.6% (43/48), respectively. Of all nodules, 47 were successfully resected with VATS (30 wedge resections; 17 anatomic resections) and 1 nodule was converted to open thoracotomy for diffuse pleural adhesion, thus the successful VATS rate was 97.9% (47/48). With respect to procedure-related complications, only minor complications (including localized pneumothorax and intrapulmonary hemorrhage) were developed and the rate of overall procedure-related complications was 37.5% (18/48), including minor pneumothorax developed in 15 of 48 nodules (31.3%) and intrapulmonary hemorrhage in 6 of 48 nodules (12.5%). CT-guided microcoil technique is a safe and effective localization method prior to VATS for the nodules in the scapula-shadowed area.

The utility of simultaneous CT-guided localization for multiple pulmonary nodules using microcoil before video-assisted thoracic surgery

BackgroundTo evaluate the feasibility and safety of microcoil in simultaneous localization for multiple pulmonary nodules before video-assisted thoracic surgery (VATS).MethodsTwenty-eight consecutive patients (26 two-nodule, 2 three-nodule; 58 nodules in total; Group A) underwent simultaneous CT-guided localization of multiple pulmonary nodules before VATS using microcoil. Successful targeting, localization, and VATS were defined as implantation of microcoil at the target site on CT image which was obtained immediately after the marking procedure, visualization of nodule location, and complete resection of the target nodule with adequate margin, respectively. Meanwhile, the clinical characteristics, localization procedure-related variables of the nodules and procedure-related complications in group A were also assessed and compared with those in a control group (221 single-localization procedures in 221 patients; Group B).ResultsSimilar rates of successful targeting, localization and VATS were observed in group A and B (96.6% vs. 98.2%; 91.4% vs. 91.0%; 100% vs. 99.1%). Although the rate of overall complications (including localized pneumothorax and intrapulmonary hemorrhage) was a bit higher in group A than that in group B (32.8% vs. 30.8%, p = 0.771), only minor complications were observed in the subjects of the two groups with no need for further treatment. In addition, the duration of simultaneous localization procedures was significantly longer than that of single localization (24 ± 7.5 vs.13 ± 6 min, p < 0.001).ConclusionsCT-guided simultaneous microcoil localization for multiple pulmonary nodules before VATS was clinically feasible and safe with acceptable increase in the procedure time. Compared with localization for a single pulmonary nodule, simultaneous microcoil localizations for multiple nodules were prone to pneumothorax and hemorrhage. However, no statistically significant differences were observed between the two groups.

A computed tomography-based nomogram to predict pneumothorax caused by preoperative localization of ground glass nodules using hook wire.

To develop and validate a CT-based nomogram to predict the occurrence of loculated pneumothorax due to hook wire placement. Patients (n = 177) were divided into pneumothorax (n = 72) and non-pneumothorax (n = 105) groups. Multivariable logistic regression analysis was applied to build a clinical prediction model using significant predictors identified by univariate analysis of imaging features and clinical factors. Receiver operating characteristic (ROC) was applied to evaluate the discrimination of the nomogram, which was calibrated using calibration curve. Based on the results of multivariable regression analysis, transfissure approach [odds ratio (OR): 757.94; 95% confidence interval CI (21.20-27099.30) p < 0.0001], transemphysema [OR: 116.73; 95% CI (12.34-1104.04) p < 0.0001], localization of multiple nodules [OR: 8.04; 95% CI (2.09-30.89) p = 0.002], and depth of nodule [OR: 0.77; 95% CI (0.71-0.85) p < 0.0001] were independent risk factors for pneumothorax and were included in the predictive model (p < 0.05). The area under the ROC curve value for the nomogram was 0.95 [95% CI (0.92-0.98)] and the calibration curve indicated good consistency between risk predicted using the model and actual risk. A CT-based nomogram combining imaging features and clinical factors can predict the probability of pneumothorax before localization of ground-glass nodules. The nomogram is a decision-making tool to prevent pneumothorax and determine whether to proceed with further treatment. A nomogram composed of transfissure, transemphysema, multiple nodule localization, and depth of nodule has been developed to predict the probability of pneumothorax before localization of GGNs.

Unusual presentations of COVID-19 pneumonia on CT scans with spontaneous pneumomediastinum and loculated pneumothorax: A report of two cases and a review of the literature.

Spontaneous pneumomediastinum (SPM) and Loculated pneumothorax (LPNX) are both generally rare clinical and radiological conditions associated with Coronavirus Disease 2019 (COVID-19). We report for the first time clinical data and radiological chest CT imaging of two patients affected by COVID-pneumonia associated with early radiological findings of SPM and LPNX.

A case of subcutaneous emphysema/mediastinal emphysema during the use of humidified high-flow nasal cannula

BackgroundHeated, humidified, high-flow nasal cannula (HHFNC) oxygen therapy allows optimal humidification of inspired gas at high flows and creates a distending pressure similar to nasal continuous positive airway pressure [1]. It has been safely used in adults with moderate hypoxemia with few complications [2, 3]. Hereby, we report serious complications occurred during HHFNC oxygen therapy.Case presentationA 53-year-old female with hemophagocytic lymphohistiocytosis (HLH) was admitted to the intensive care unit because of respiratory failure. After weaning from mechanical ventilation which lasted for 2 weeks, HHFNC therapy at 40 L/min with an FiO2 of 0.5 was started for hypoxemia. Four days later, dyspnea and hypoxemia occurred and chest X-ray and CT scan revealed localized pneumothorax, subcutaneous emphysema, and massive pneumomediastinum. After cessation of HHFNC, respiratory condition improved.ConclusionSubcutaneous emphysema, pneumothorax, and pneumomediastinum should be notified as a serious complication during HHFNC therapy.

CLOSURE OF A BRONCHOPLEURAL FISTUAL USING AN AMPLATZER DEVICE UNDER FLUOROSCOPIC AND BRONCHOSCOPIC GUIDANCE

SESSION TITLE: Case Report Semifinalists 4 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Bronchopleural fistula (BPF) is a rare complication with potentially fatal consequences following pulmonary resection. Incidence has been reported at 0.5% following lobectomy and is more prevalent in patients undergoing resection for malignant versus benign conditions. Correction of BPF is accomplished utilizing surgical and endoscopic techniques. Here, we describe an endobronchial closure of a BPF using an Amplatzer device in a patient who was deemed a poor surgical candidate. CASE PRESENTATION: A 76 year-old female with history of bronchioloalveolar carcinoma status-post right upper and right middle lobectomy complicated by BPF and invasive aspergillus pneumonia who presented with worsening dyspnea. She was treated with anti-fungal therapy for aspergillus. However despite appropriate treatment, her dyspnea worsened with associated productive cough. Computed tomography (CT) of the chest revealed a loculated pneumothorax which communicated with the bronchus stump and a 5mm bronchopleural fistula. Thoracic surgery evaluation deemed her to be a poor candidate for surgical closure given her frailty, age, anatomy, and chronicity of the BPF. Institutional review board approved the off-label and compassionate humanitarian use of the Amplatzer ASD occluder device. The procedure was done under general anesthesia. A 7mm device was chosen. After general anesthesia, a rigid bronchoscope was introduced into the trachea. Through this, a flexible bronchoscope was advanced to the right bronchus and the fistula visualized. A Jag wire was advanced into the pleural cavity via the BPF and position confirmed by fluoroscopy. The 7F delivery catheter and delivery system was prepared and the ASD closure device loaded. Delivery catheter was advanced into the pleural space over the wire. The left atrial disc was deployed in the right upper lobe pleural cavity under fluoroscopy. The disc was retracted to the bronchial wall and then the right atrial disc was deployed in the right mainstem bronchus under direct bronchoscopic visualization. The device was released after it was seen to be in good position with rims appearing flush against the bronchial wall. The patient tolerated the procedure well. At follow-up, the patient reported significant improvement in symptoms and exercise tolerance. Repeat bronchoscopy revealed a small air leak that is currently being monitored. DISCUSSION: Postoperative complication following pulmonary resection is the most common etiology of BPF. As these patients may be particularly frail and poor surgical candidates it is important to present all available therapeutic options. We described a case of BPF closure using an Amplatzer device with good results. Further studies should be performed to assess true safety and efficacy. CONCLUSIONS: Amplatzer occluder devices may be a viable option to correct BPF in patients who are poor candidates for surgical correction. Reference #1: Cerfolio, Robert James. “The Incidence, Etiology, and Prevention of Postresectional Bronchopleural Fistula.” Seminars in Thoracic and Cardiovascular Surgery, vol. 13, no. 1, Jan. 2001, pp. 3–7 Reference #2: Lois, Manuel, and Marc Noppen. “Bronchopleural Fistulas: An Overview of the Problem With Special Focus on Endoscopic Management.” Chest, vol. 128, no. 6, Dec. 2005, pp. 3955–65. Reference #3: Endobronchial closure of bronchopleural fistula using Amplatzer device. J Thorac Dis. 2015 Aug; 7(8): 1478–1482. DISCLOSURES: No relevant relationships by Amarbir Bhullar, source=Web Response no disclosure on file for Pravachan Hegde; no disclosure on file for Elliot Ho; No relevant relationships by Kassra Poosti, source=Web Response No relevant relationships by Chirag Rajyaguru, source=Web Response No relevant relationships by Uday Sandhu, source=Web Response no disclosure on file for Rohit Srivastava

CATAMENIAL PNEUMOTHORAX: A MANAGEMENT CHALLENGE

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Catamenial pneumothorax (CP) is a rare clinical entity presenting with recurrent pneumothorax in women of reproductive age (1). Presence of ectopic endometrial tissue in thorax leads to their activation with each menstrual cycle. We report a unique case of a young female who presented with recurrent spontaneous pneumothorax despite video assisted thoracoscopic surgery (VATS). CASE PRESENTATION: A 36-year-old female with history of endometriosis, CP status post VATS about 4 months prior to this presentation, DVT, was referred to our ER for admission after she was found to have large right pneumothorax on a CT chest done as outpatient for chest discomfort. She was hemodynamically stable with SpO2 97% on room air. CT chest revealed a very large loculated right pneumothorax with left mediastinal shift and extensive pleural thickening. Initially she underwent a pigtail catheter placement in the largest pocket. Despite the pigtail drainage, patient continued to have air leak and mediastinal shift. Thus, a decision was made to perform VATS again. Pleural biopsy and VATS pleurodesis were performed with placement of 12F, 19F, 28F chest tubes. Mediastinal shift resolved but she continued to have small pneumothorax. On day 16, she was discharged with a chest tube and outpatient follow-up. Chest tube was removed on one week follow up in the clinic. She continued to have small loculated right sided pneumothorax. Pleural biopsy obtained during VATS, showed positive paired-box gene8 (PAX8) in epithelial lining compatible with presence of endometrial tissue in pleura. She is currently on progesterone only mini pill and is closely followed up in clinic. DISCUSSION: Thoracic endometriosis is the most common site for extra pelvic endometriosis with CP being a common presentation. It mostly affects right side (85-90%) like in our case. Characteristic findings associated with CP include defects of diaphragm like perforation, stomata, pores and fenestrations, which can vary in size, shape and numbers (2). With this case, we emphasize that the physicians should be aware of this relatively uncommon clinical entity when encountering young female with recurrent pneumothorax. Even after confirmed diagnosis, CP poses a treatment challenge as it can continue to cause recurrent large pneumothoraces despite VATS and hormonal therapy. Patients can develop pleural thickening and loculations which makes management of future pneumothoarcses even more difficult. No clear guidelines exist on management of CP. With the disease affecting young population and having a significant effect on lifestyle, it is prudent that more research should be done for CP management. CONCLUSIONS: CP is an uncommon cause of recurrent pneumothorax. Histologic finding of endometrial tissue on pleural biopsy is often required to confirm the diagnosis. CP is usually managed with hormonal therapy and VATS but needs further investigation. Reference #1: Bagan P, et al. Catamenial pneumothorax: retrospective study of surgical treatment. Ann Thorac Surg 2003;75:378-81. Reference #2: Visouli AN, et al. Catamenial pneumothorax: a rare entity? Report of 5 cases and review of the literature. J Thorac Dis. 2012 Nov;4(Suppl 1):17–31. DISCLOSURES: No relevant relationships by Nidhi Aggarwal, source=Web Response No relevant relationships by Vivek Kumar, source=Web Response No relevant relationships by Yizhak Kupfer, source=Web Response No relevant relationships by Jignesh Patel, source=Web Response No relevant relationships by Anand Rai, source=Web Response No relevant relationships by Arjun Saradna, source=Web Response No relevant relationships by Ankur Sinha, source=Web Response No relevant relationships by Parita Soni, source=Web Response

Old Friend, New Face: Actinomyces Presenting as a Loculated Pneumothorax

Old Friend, New Face: Actinomyces Presenting as a Loculated Pneumothorax

A diagnosis more than skin deep: A case of late-stage pulmonary langerhans’ cell histiocytosis with skin lesions

Introduction: Langerhans’ cell histiocytosis (LCH) is a group of rare diseases with a wide variety of presentations across age groups. We describe a case of pulmonary LCH diagnosed at a late stage despite having additional skin findings for several years.Case description: A 32-year-old male presented with acute exacerbation of chronic dyspnea resulting in markedly decreased functional capacity as well as cutaneous lesions. He had smoked cigarettes for 10 years with no occupational exposures. The patient also complained of a pruritic rash in his axillary and groin areas. His vitals were within normal limits. His exam was notable for diminished right lung sounds and expiratory wheezes bilaterally. A chest x-ray showed marked emphysema and bilateral upper lobe reticular opacities suggestive of scarring. Computerized tomography of the chest showed loculated right pneumothorax and hyperinflated lungs with destructive changes secondary to numerous irregular, thick walled cysts and scatteredirregular pulmonary nodules. Diagnosis was ultimately confirmed with biopsy of concomitant cutaneous lesions and characteristic radiographic findings on Chest CT. The patient started inhaled corticosteroids, inhaled anticholinergic, and inhaled short-acting beta agonists. He was sent home with oxygen and strongly encouraged to abstain from smoking.Discussion: LCH is characterized by end-organ infiltration of proliferating monoclonal Langerhans’ cells, a histiocyte involved in antigen presentation. The highest incidence of LCH is between ages 5-10 years; the adult incidence is estimated to be less than half as frequent than the pediatric, about one patient in 500,000. LCH most commonly involves the skin, bones, and lungs. Pulmonary LCH (PLCH) is interesting in that it has a peak incidence in ages 20-40 years and occurs almost exclusively in smokers (&gt; 90% of cases). Conclusion: Smoking cessation is the cornerstone of management of PLCH. It has been hypothesized that tobacco smoke can incite the production of cytokines by alveolar macrophages, leading to increased recruitment of histiocytes to the lung parenchyma. In isolated pulmonary pathology, lung transplant with smoking cessation is often curative.

The pressure-dependent air leak after partial lung resection

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

Can Routine Trauma Bay Chest X-ray be Bypassed with an Extended Focused Assessment with Sonography for Trauma Examination?

The objective of this study was to investigate the feasibility of using ultrasound (US) in place of portable chest x-ray (CXR) for the rapid detection of a traumatic pneumothorax (PTX) requiring urgent decompression in the trauma bay. All patients who presented as a trauma alert to a single institution from August 2011 to May 2012 underwent an extended focused assessment with sonography for trauma (FAST). The thoracic cavity was examined using four-view US imaging and were interpreted by a chief resident (Postgraduate Year 4) or attending staff. US results were compared with CXR and chest computed tomography (CT) scans, when obtained. The average age was 37.8 years and 68 per cent of the patients were male. Blunt injury occurred in 87 per cent and penetrating injury in 12 per cent of activations. US was able to predict the absence of PTX on CXR with a sensitivity of 93.8 per cent, specificity of 98 per cent, and a negative predictive value of 99.9 per cent compared with CXR. The only missed PTX seen on CXR was a small, low anterior, loculated PTX that was stable for transport to CT. The use of thoracic US during the FAST can rapidly and safely detect the absence of a clinically significant PTX. US can replace routine CXR obtained in the trauma bay and allow more rapid initiation of definitive imaging studies.

Analysis of serious respiratory complications in PICU in children with measles

To evaluate the characteristics of the serious complications of 17 cases with measles in ICU. Seventeen cases with measles with serious complications in ICU in Anhui Provincial Children's Hospital were recruited from May 2012 to May 2013. Clinical characteristics, image finding, and prognosis were analyzed retrospectively. IgM antibody was positive in all the 17 cases, which included 9 male cases, 8 female cases, and their age was from 2 months to 10 years. All the 17 patients received mechanical ventilation because of severe respiratory distress within 1 week of onset, of which 14 cases were complicated with acute respiratory distress syndrome (acute ARDS), 6 cases of tension pneumothorax, 3 cases were complicated with bronchitis, laryngeal obstruction III degrees, and totally 7 cases died. The survived 10 patients were followed up for 1 year, 1 patient with localized pneumothorax, bronchopleural fistula, 1 case of mild pulmonary fibrosis, 1 case of acute laryngitis with persistent hoarseness, and mild inspiratory dyspnea were found. The remaining 7 cases fully recovered. Fourteen cases failed to inoculate measles vaccine. A higher risk of death and poor prognosis were found in children with measles who needed to be treated in PICU, especially for ARDS with pneumothorax. Laryngitis needed long time to cure and had weaning difficulties, and the case associated with pleural effusion or bronchopleural fistula must be treated with surgery, and the patients easily develop secondary bacterial infection.

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Patients presenting for an elective or emergency surgery with pre-existing chronic renal failure (CRF) has certain anesthetic considerations. Central neuraxial block for these patients is controversial, because all these patients will be invariably on fluid restriction. If such patient presents with pulmonary complications and cardiac complications which are relative contraindications for general anesthesia then the anesthetic management becomes trickier. We had a patient with CRF, presented with inter-trochanteric fracture of femur for surgical fixation. The patient also had left side loculated pneumothorax, right side bronchiectatic changes and permanent cardiac pacemaker for complete heart block which were challenges for general anesthesia too. Finally the surgery was done

On the nature of pleural involvement in necrotizing pneumonia: A report of two cases of life threatening late complications

Suppurative complications of pneumonia such as empyema, lung abscess, pyopneumothorax, and necrotizing pneumonia (NP) are uncommon in children. Over the last decade an increasing incidence of NP has been reported. Streptococcus pneumoniae continues to be the predominant causative organism of NP, and while sporadic cases were reported prior to routine administration of heptavalent pneumococcal vaccine, a marked increase in NP appears to relate to replacement pneumococcal strains. Pleural involvement is almost universal in NP, and the course of pleural disease often determines its duration and outcome, particularly as it relates to complication of bronchopleural fistula. Cavities are formed in NP within the lung parenchyma and in the pleural space as the fibrosing pleural process organizes. The similarity of the radiologic appearance of parenchymal and pleural space cavities often makes the differentiation of pneumatocele versus residua of loculated pneumothorax challenging. The prevailing perception from most reports on childhood NP is of a favorable outcome with conservative approach. We report two pediatric cases with pneumonia who presented with prolonged fever despite antibiotic treatment, eventually diagnosed with NP. After stabilization on prolonged IV antibiotics, and weeks after discharge, they presented with unexpected acute respiratory failure due to a life-threatening tension air collection. In this article we discuss the nature of NP, its typical presentation, benign course and outcome, albeit its potential to cause serious late complications in the light of our recent experiences. Increasing awareness of such complications will result in more careful follow-up and in providing appropriate recommendations to parents of patients recovering from NP.