Lung Re-expansion Research Articles

REPERFUSION PULMONARY EDEMA AFTER RESECTION OF A MALIGNANT SOLITARY FIBROUS TUMOR OF THE PLEURA MANAGED WITH VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Solitary fibrous tumors of the pleura (SFTP) are rare tumors that account for 5% of all primary pleural tumors. SFTP originate from the submesothelial mesenchymal layer of the pleura from primitive fibroblast or mesenchymal cells. Although most are benign and can be cured by complete resection, malignant forms of SFTP are known to recur more frequently. CASE PRESENTATION: A 66-year-old female with history of hypertension and prior resection of an SFTP via median sternotomy in 2004 (pathology unknown) presented with increasing dyspnea on exertion over the previous four weeks, greatly decreasing her functional status. Imaging revealed a large soft tissue mass occupying most of the right hemithorax and displacing the mediastinum to the left (Figure 1). Patient underwent resection of the large right SFTP via a right thoracotomy with lung isolation via a double lumen ET tube. Upon re-expansion of the right lung at the end of the case, patient became acutely hypoxic and hypotensive, with massive bilateral pulmonary edema on bronchoscopy. Condition persisted despite aggressive suctioning and increased ventilatory and vasopressor support, and patient was emergently placed on venovenous (VV) ECMO in the OR via a 21F right femoral vein cannula and a 17F right internal jugular vein cannula. The patient's hypoxia resolved and blood pressure stabilized on vasoactive drips, while massive pulmonary edema resolved gradually through discharge on POD15. Post-op course complicated by tamponade physiology that required emergent pericardiocentesis, AKI requiring hemodialysis (with full recovery), and atrial fibrillation requiring cardioversion, with resultant stabilization in hemodynamics. ECMO support was discontinued on POD3. Final pathology revealed a 22 x 18 x 10.5cm malignant SFTP with 5 mitotic figures per 10 high power fields. DISCUSSION: RPE is characterized by pulmonary edema plus or minus clinical symptoms, sometimes including hemodynamic instability, after rapid re-inflation of a previously collapsed lung. Although almost exclusively described after drainage of pneumo- or hemothorax in the literature [1], this rare phenomenon is the most likely cause of the massive pulmonary edema seen in our patient with long-term lung compression by SFTP. The pathophysiology of RPE likely includes tissue reperfusion, hypoxia, and free radial damage, among other processes, as the mechanism for lung damage and pulmonary edema. Treatment is generally supportive based on the clinical manifestations of RPE, including ECMO in our case and only two other cases reported in the literature [2, 3]. CONCLUSIONS: VV ECMO allows for complete lung rest while providing adequate oxygenation for end organ perfusion, although not without possible complications, most concerning of which are hemorrhagic. This case is the first to demonstrate the successful use of VV ECMO in a very rare case of RPE after resection of a malignant SFTP. REFERENCE #1: Meeker JW, Jaeger AL, Tillis WP. An uncommon complication of a common clinical scenario: exploring reexpansion pulmonary edema with a case report and literature review. J Community Hosp Intern Med Perspect. 2016; 6:32257. REFERENCE #2: Tung YW, Lin F, Yang MS et al. Bilateral developing reexpansion pulmonary edema treated with extracorporeal membrane oxygenation. Ann Thorac Surg 2010; 89:1268-1271. REFERENCE #3: Shires AL, Green TM, Owen HL et al. Case 4--2009. Severe reexpansion pulmonary edema after minimally invasive aortic valve replacement: management using extracorporeal membrane oxygenation. J Cardiothorac Vasc Anesth 2009; 23:549-554. DISCLOSURES: No relevant relationships by Ann Defnet, source=Web Response No relevant relationships by Harvey Pass, source=Web Response No relevant relationships by Deane Smith, source=Web Response No relevant relationships by Gerardo Velez, source=Web Response

DEBILITATING SUBCUTANEOUS EMPHYSEMA IN THE SETTING OF RESOLVING SECONDARY PNEUMOTHORAX

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Subcutaneous emphysema (SE) is defined as the presence of air under subcutaneous tissues manifesting as swelling and crepitus. This typically benign self-limiting condition can rapidly deteriorate if left unchecked. We present a case of debilitating SE in the setting of pneumothorax management. CASE PRESENTATION: A 72-year-old man with severe chronic obstructive pulmonary disease presented with an iatrogenic small right-sided pneumothorax immediately after CT-guided biopsy of a pulmonary nodule. He improved after right thoracostomy tube insertion. Twenty-four hours after removal of the tube, he experienced dyspnea and chest pain. Physical exam was pertinent for absent breath sounds on the right hemithorax. A new moderately sized right sided lateral pneumothorax was noted on emergent chest x-ray. Due to worsening respiratory failure, he underwent intubation prior to being transferred to the intensive care unit. Upon chest tube placement, he was noted to have extensive crepitus on the bilateral neck, right hemithorax, abdomen, and pelvis. He was successfully extubated and repeat imaging confirmed resolution of pneumothorax with complete lung re-expansion, thus the chest tube was shifted from suction to water seal. Five minutes after, the subcutaneous emphysema rapidly progressed to involve the entire face as evidenced by worsening bilateral periorbital edema, closure of palpebral fissures, and high patient distress. Infraclavicular blowhole incisions were then placed and the chest tube was placed back on 20 mmHg suction. He was continued on suction for three more days until eventual resolution of the subcutaneous emphysema. DISCUSSION: SE is defined as de novo infiltration of air in the subcutaneous layers of the skin. Potential causes include surgeries, trauma, infections, and idiopathic etiology, with an incidence of 0.43% to 2.34%. Complications of extensive SE include dysphagia and compression of the airway, barotrauma, expanding pneumothorax, reduced cardiac preload, skin necrosis, amongst others. Debilitating features include anxiety, dysphagia, dysphonia, and significant respiratory or circulatory compromise. Our patient had a higher risk for SE due to the timing of the thoracotomy tube insertion while the patient was exposed to positive pressure. Worsening of the SE was due to premature discontinuation of chest tube suction. Although the pneumothorax has already resolved, it is prudent to delay transitioning the suction to water seal until the SE has stabilized. Infraclavicular blow-hole incisions, subcutaneous drains, fenestrated angiocatheters, vacuum assisted dressings and increasing suction on a pre-existing chest tube have also been described to expedite the time to recovery from debilitating SE CONCLUSIONS: Early identification and management are essential to decrease SE-related complications and mortality. More studies are needed to explore ideal management options. REFERENCE #1: Aghajanzadeh M, Dehnadi A, Ebrahimi H, Fallah Karkan M, Khajeh Jahromi S, Amir Maafi A, Aghajanzadeh G. Classification and Management of Subcutaneous Emphysema: a 10-Year Experience. Indian J Surg. 2015 Dec;77(Suppl 2):673-7 REFERENCE #2: Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med. 1984 Jul;144(7):1447-53 REFERENCE #3: Jones P, Hewer R, Wolfenden Het al. Subcutaneous emphysema associated with chest tube drainage. Respirology 2001; 6(2): 87–89 DISCLOSURES: No relevant relationships by Gustavo Avila, source=Web Response No relevant relationships by Jessica Baek, source=Web Response No relevant relationships by Renuka Reddy, source=Web Response No relevant relationships by Jodi Renner, source=Web Response No relevant relationships by Larnelle Simms, source=Web Response No relevant relationships by Laura Suzanne Suarez, source=Web Response No relevant relationships by Claudia Tejera Quesada, source=Web Response

IS A HIGH HEMATOCRIT USEFUL TO REVEAL AN EARLY REEXPANSION PULMONARY EDEMA?

Introduction The Reexpansion Pulmonary Edema (RPE) is a rare condition, lethal in 20%, resulting after a fast drainage of pleural effusion, pneumothorax or a huge mediastinal mass. We report a case of RPE after treatment for pleural effusion. Beside typical symptoms as hyponatremia, hyperkalaemia, hyperglycaemia, an interesting finding was a high haematocrit value (>65%), never described. We want to stress the importance of early recognition of signs and symptoms: inadequate or delayed treatment may lead to a fatal outcome. Methods After two months from a cardiac revascularization, a 68-year-old male patient was re-admitted for respiratory failure (SpO2 Results The pulmonary edema diminished gradually and the patient was extubated after one day: the haematocrit was 42%. The radiography showed a reduction of edema (Fig.1C). At third day, the patient was discharged to the ward. Discussion Recently Meeker1 defined RPE “an uncommon complication of a common clinical scenario” with an unclear pathophysiology. Age, clinical status, rapid thoracentesis or chest drainage are important risk factors for this rare iatrogenic complication. Literature shows a removing volume of 1200-1800 ml as a safe cut-off. This process, resulting in local and systemic factors, starts with an acute lung reexpansion and consequently insurgence of pulmonary edema, related to the hydrostatic forces on pulmonary capillaries: the return of high perfusion pressure after rapid thoracentesis or chest drainage is associated with negative pressure and vessel hypoxic constriction. This reperfusion increases free oxygen radicals and anoxic stress resulted in the production of cytokines by the endothelium: selectin, TNF-a and IL-1b, generating increased protein permeability. We assume that the drop in osmotic pressure causes the leakage of liquids into the extracellular space leading to a rapid increase in the hematocrit value associated to hyponatremia: these early alerts can help the staff to avoid a rapidly worsening of respiratory function and to start a correct treatment.

Is there an ideal position and size of chest drain following anatomical lung resection?

BackgroundChest drains are placed after surgery to enable lung re-expansion. However, there remains little guidance on optimal placement. This study aims to identify the ideal size and position for chest drain insertion with regards to post-operative outcomes. Methods383 patients undergoing lobectomy in 1-year had their chest drain size and x-ray position noted (1 (apical), 2 (mid-zone) or 3 (basal)). Primary outcome was residual air space on immediate post-operative x-ray. Secondary outcomes were length of drain in situ (<72 versus ≥72 h), persisting pleural effusion, surgical emphysema, post-operative pneumonia (POP), and length of hospital stay (<5 versus ≥5 days). Fisher's exact analysis for the primary outcome and binary logistic regression analysis for all outcomes were used. Results presented as odds ratios (OR±95%CI). ResultsUnivariate analysis for residual air space showed increased risk in area 2 (OR = 1.61, p = 0.041) and 3 (OR = 2.59, p = 0.0043) compared with area 1. Multivariate analysis for residual air space showed increased risk in area 2 (OR = 2.39, p < 0.001) and 3 (OR = 2.86, p < 0.001) compared with area 1. Drain size had no impact on residual air space in univariate or multivariate analysis. Multivariate analysis showed area 2 drains remained in situ for >72 h (OR = 1.49, p = 0.017), had persisting effusions (OR = 2.03, p = 0.004) and POP (OR = 2.10, p = 0.023) compared with area 1. This risk is magnified further for drains in area 3. Drains ≥28F had reduced risk of surgical emphysema (OR = 0.23, p = 0.027) in multivariate analysis. ConclusionA ≥28F, apical chest drain reduces the risk of post-operative complications, allowing early removal and discharge.

Efficacy and Survival after Palliative Radiotherapy for Malignant Pulmonary Obstruction.

Introduction: The purpose of this study was to determine the efficacy of palliative radiotherapy (PRT) for patients with pulmonary obstruction from advanced malignancy and identify factors associated with lung re-expansion and survival. Materials and Methods: We reviewed all patients treated with PRT for malignant pulmonary obstruction (n = 108) at our institution between 2010 and 2018. Radiographic evidence of lung re-expansion was determined through review of follow-up CT or chest X-ray. Cumulative incidence of re-expansion and overall survival (OS) were estimated using competing risk methodology. Clinical characteristics were evaluated for association with re-expansion, OS, and early mortality. Treatment time to remaining life ratio (TT:RL) was evaluated as a novel metric for palliative treatment. Results: Eighty-one percent of patients had collapse of an entire lung lobe, 46% had Eastern Cooperative Oncology Group (ECOG) performance status 3-4, and 64% were inpatient at consultation. Eighty-four patients had follow-up imaging available, and 25 (23%) of all patients had lung re-expansion at median time of 35 days. Rates of death without re-expansion were 38% and 65% at 30 and 90 days, respectively. Median OS was 56 days. Death within 30 days of PRT occurred in 38%. Inpatients and larger tumors trended toward lower rates of re-expansion. Notable factors associated with OS were re-expansion, nonlung histology, tumor size, and performance status. Median TT:RL was 0.11 and significantly higher for subgroups: ECOG 3-4 (0.19), inpatients (0.16), patients with larger tumors (0.14), those unfit for systemic therapy (0.17), and with 10-fraction PRT (0.14). Conclusion: One-fourth of patients experienced re-expansion after PRT for malignant pulmonary obstruction. Survival is poor and a significant proportion of remaining life may be spent on treatment. Careful consideration of these clinical factors is recommended when considering PRT fractionation.

Efficacy and safety of position selection combined with intra-pleural thrombin injection in the treatment of postoperative persistent air leakage in bullous pulmonary-pleural diseases

Objective: To explore the efficacy and safety of position selection in combination with intra-pleural thrombin injection in the treatment of persistent air leakage (PAL) after medical thoracoscopic treatment of bullous pulmonary-pleural diseases (e.g. spontaneous pneumothorax or giant emphysematous bulla). Methods: This was a prospective study conducted in Rizhao Hospital of Traditional Chinese Medicine from August 2018 to November 2020. Twenty patients(19 males,1 female) with a mean age of (62.3±8.1) years met the diagnostic criteria for PAL which was defined as the air leak persisted more than 3 days despite of the closed thoracic drainage after medical thoracoscopic treatment of bullous pulmonary-pleural diseases.They received the following treatment procedures (referred to as "position plus"):①Pleural cavity injection (50% glucose 20 ml+thrombin 5 000 U).②Changing the patient's position under continuous negative pressure suction to find the position causing the complete stop or significant reduction of air leakage, and keeping in the position for 24-48 hours.③If the PAL wasn't stopped 48 hours later, the procedures above would be repeated.The duration of air leakage after "position plus", times of pleural cavity injection, condition of lung re-expansion, recurrence of air leakage and complications during hospitalization were recorded. Descriptive statistics were used to summarize the results:¯x±s or M(P25, P75) for continuous variables; frequency and percentages for categoric variables. Results: A total of 20 patients were included. The average duration of air leakage after"position plus" was (1.32±0.97) days. The times of pleural cavity injection required were 1.0(1.0, 1.0).All the patients showed good lung re-expansion in review of imaging after PAL was stopped. One patient had recurrent air leakage during hospitalization. No serious complications occurred. Conclusion: The comprehensive "position plus" intervention method is effective, safe and easily operating for the treatment of PAL after medical thoracoscopic treatment of bullous pulmonary-pleural diseases.

Pleural space management after lung transplant: Early and late outcomes of pleural decortication

Pleural complications after lung transplant may restrict allograft expansion, requiring decortication. However, its extent, indications, risk factors, and effect on allograft function and survival are unclear. From January 2006 to January 2017, 1,039 patients underwent primary lung transplant and 468 had pleural complications, 77 (16%) of whom underwent 84 surgical decortications for pleural space management. Multivariable time-related analysis was performed to identify risk factors for decortication. Mixed-effect longitudinal modeling was used to assess allograft function before and after decortication. Cumulative number of decortications per 100 transplants was 1.8, 7.8, and 8.8 at 1 month, 1 year, and 3 years after transplant, respectively. Indications for the 84 decortications were complex effusion in 47 (56%), fibrothorax in 17 (20%), empyema in 11 (13%), and hemothorax in 9 (11%). Thoracoscopic operations were performed in 52 (62%) and full lung re-expansion was achieved in 76 (90%). Complications occurred after 30 (36%) decortications, with 15 pulmonary complications (18%), including 2 patients requiring extracorporeal support due to worsening function. Ten reinterventions occurred via thoracentesis (2), tube thoracostomy (1), and reoperation (7). In-hospital and 30-day mortality was 5.2% (n = 4/77). Forced expiratory volume in 1 second increased from 50% to 60% within the first year after decortication, followed by a slow decline to 55% at 5 years. Postdecortication survival was 87%, 68%, and 48% at 1, 3, and 5 years, respectively. Despite high risk of reoperative surgery, decortication after lung transplant allows salvage of pleural space and graft function with a reasonable morbidity profile.

Tuberculous bronchopleural fistula.

Key messageTuberculous bronchopleural fistula is a rare complication of pulmonary tuberculosis with presentation ranging from patients who are asymptomatic with incidental findings on imaging to those who present with acute tension pneumothorax.

The efficacy of balloon dilatation in clinical improving period for patients who suffered from actively caseating endobronchial tuberculosis and central airway stenosis

Objective: To investigate the efficacy of balloon dilatation performed for patients who suffered from actively caseating endobronchial tuberculosis (EBTB) and central airway stenosis in clinical improving period who's bronchus has not formed mature scar tissue. Methods: A total of 152 tuberculous unilateral main bronchus stenosis patients (23 male and 129 female) who received treatment in Hunan Chest Hospital from January 1st 2014 to December 31st 2018 were included in this retrospective analysis. The age was 15-66 (33.3±11.9) years old. All patients received routine anti-tuberculosis chemotherapy. Sixty-four of them who suffered from actively caseating EBTB and unilateral main bronchus stenosis received cryotherapy and endobronchial isoniazid (INH) administration till the caseating necrosis in stenotic bronchus was disappeared and ulcers were recovered, and then received balloon dilatation combined with cryotherapy, were test group. Eighty-eight of them who suffered from fibrostenotic EBTB received balloon dilatation combined with cryotherapy were control group. We analyzed the efficacy and complications after treatments. Results: The lung re-expansion rate after treatment in test group was higher than the control group, and the differences were statistically significant [74.0%(37/50) vs. 37.9%(22/58), χ²=14.094, P<0.001]. The 6-month re-stenosis rate in test group was lower than control group, and the differences were statistically significant [10.9%(7/64) vs. 30.7% (27/88), χ²=8.318, P=0.004]. The differences of diameter and diameter variation after balloon dilatation, immediate effective rates, average times of balloon dilatation and procedure-related bleeding (<10 ml) rates, chest pain rates had no statistical signification in two groups. Severe complications including fatal bleeding (>100 ml) and mediastinal emphysema did not occur during our procedures. Conclusions: Performing balloon dilatation for patients who suffered from actively caseating EBTB and central airway stenosis in the clinical improvement period, when caseous necrosis tissue disappeared and ulcers were recovered, not only helps to perform interventional procedures on distal bronchus in time, increase the rate of lung re-expansion, can also reduce the rate of re-stenosis after 6 months, so it is effective and safe.

A Retrospective Analysis of the Palliative Surgical Treatment in Patients with Malignant Pleural Effusion

Abstract Introduction: The formation of malignant pleural effusion (MPE) is a clinical manifestation of an advanced malignancy or its dissemination. The focus of treatment is primarily palliative and aimed at relieving symptoms, especially dyspnoea. Material and Methods: Clinical data from patients who were hospitalized at the Clinic of Thoracic Surgery, JFMED CU and Martin University Hospital, in the years 2015–2019 were retrospectively explored and statistically analyzed based on their medical records. Results: From the group of patients with proven MPE (n=67), 32 patients were male (48%) and 35 were female (52%). The mean age was 62.3 years (65.4 for males and 59.4 for females). The three most common primary malignancies were lung cancer (n=24), breast cancer (n=14), and kidney cancer (n=6). In 38 patients with MPE a talc pleurodesis via VATS was performed, with a median survival of 341 days (95% CI 256–859). Drainage following the talc slurry pleurodesis was performed in 10 patients with a median survival of 91.5 days (95% CI 64-NA). Ten patients with MPE underwent drainage only. The overall median survival time after all types of surgical interventions was 301 days (95% CI 207-389 days). Conclusion: Management of MPE depends on the patient´s prognosis. A definitive intervention is required in patients with a long-term survival, while in patients with a short life expectancy procedures leading to the shortest hospital stay are preferred. Videothoracoscopic procedures with pleurodesis represent an effective treatment for patients with symptomatic MPE with a good performance status, presence of lung re-expansion following pleural drainage or expected survival.

Can intrapleural alteplase treatment be an alternative to videothoracoscopic deloculation and decortication in pleural empyema?

IntroductionChest tube drainage is the first step in the management of complicated pleural effusions that have turned into empyema. In cases where adequate drainage cannot be provided or deloculation is required, intrapleural fibrinolytic therapy or surgical deloculation can be performed. Alteplase is a suitable agent for intrapleural fibrinolytic therapy. On the other hand, video-assisted surgery is an effective and minimally invasive treatment option for lung re-expansion.AimThe effect of intrapleural alteplase irrigation applied through the thoracic tube in the treatment of pleural empyema was investigated and whether it could be an alternative technique to video-assisted thoracoscopic surgery was evaluated.Material and methodsThe results of patients who were treated for empyema in our clinic were evaluated retrospectively. Twenty-one patients who underwent tube thoracostomy + intrapleural alteplase and 28 patients who underwent VATS deloculation were included in the study.ResultsThe study included 35 male and 14 female patients. There were 21 patients in group 1, and 28 patients in group 2. The mean age was 50.6. The average length of thoracic tube stay was determined as 7.1 and 6.96 days. The duration of hospital stay in this group was 6.73 and 6.35 days. In 17 (81%) patients in group 1, the treatment was discontinued without the need for surgery.ConclusionsVATS-D is an effective option in the treatment of pleural empyema. However, as seen in our study, intrapleural alteplase application is at least as effective as VATS-D in terms of treatment success.

Occurrence and Management of Empyema Thoracis During Covid-19 Times

Introduction: Empyema is defined as an infected pleural fluid collection, evidenced either by purulent fluid or the presence of bacterial organisms. The aim of this study is to highlight the importance of early diagnosis and management of empyema in an attempt to avoid needless procedures and dreaded complications while shining a light into the warrant of a multidisciplinary approach that would had a paramount significance during the lockdown period in Greece, between March-June of 2020 due to COVID-19, in ameliorating those issues. Patients and Methods: During the aforementioned period 12 patients were treated at our Department, 11 of them were male, ages ranging from 22-71 years old. The cause of empyema was parapneumonic effusion from a bacterial pneumonia in 10 patients and the other 2 were tuberculous empyema and extension of an intraabdominal process (Diffuse large B-cell lymphoma of the stomach). Predominately the patients were admitted to our Department with stage III empyema. Diagnosis was confirmed with CT scan and drainage of frank pus from the chest tube. All patients underwent chest tube insertion and antibiotic therapy nonetheless 9 of them required surgical management with VATS or open decortication. Results and Conclusion: The impedance in seeking medical advice due to fear of COVID-19 and the insufficiency of an interdisciplinary approach in the management of those patients were determined as the reason for such high admittance with stage III empyema. The decision of open vs VATS decortication was made based on the medical status and history of each individual, the stage of the empyema and ultimately our ability to achieve the two primary goals of empyema treatment, complete evacuation, and lung reexpansion [1]. Eight patients underwent open decortication and drainage and one managed with VATS decortication. Postoperative complications were encountered in 3 patients which included prolonged air leak, surgical wound infection, and septic shock. One patient died from multiple organ failure due to postoperative septic shock. The duration of chest tube drainage varied from 5-15 days. The mean hospital stay was 13,5 days.

Laparoscopic Repair for Full Thickness Resection of Diaphragm Metastases in Ovarian Cancer

Study Objective To describe the laparoscopic surgical technique to safely repair a full thickness diaphragm ovarian cancer resection, as well as the intraoperative trans-diaphragmatic pneumothorax decompression and lung re-expansion technique. Additionally, the role of minimally invasive surgery to resect diaphragm metastases in ovarian cancer will be discussed. Design Surgical educational video. Setting Tertiary care center at an academic institution. Operating room procedure with patient on lithotomy with reverse Trendelenburg position and a leftward tilt. Patients or Participants Case description of a 39-year-old patient with stage IIIB high grade serous carcinoma of the ovary who presented for interval debulking surgery. Interventions Laparoscopic cytoreduction with resection of diaphragmatic metastases. This video emphasizes the most important surgical steps to safely perform a minimally invasive full thickness right hemi-diaphragmatic defect repair after resection of full thickness ovarian cancer metastases. A trans-diaphragmatic lung re-expansion technique using a suction catheter with purse string suture and Valsalva is shown. Measurements and Main Results N/A Conclusion Laparoscopic resection of diaphragm metastases with intraoperative trans-diaphragmatic pneumothorax decompression is feasible and safe in selected patients. Surgical expertise with adequate laparoscopic needle handling is necessary for a safe repair.

69-YEAR-OLD MALE WITH ENTRAPPED CHEST TUBE: COMPLICATION OF CPR

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Cardiopulmonary resuscitation (CPR) is a lifesaving intervention routinely performed in medical institutions. However, it is associated with multiple complications including rib fractures requiring thoracostomy tube (TT) insertion. Additionally, there is a paucity of evidence identifying complications of CPR with a TT present. Here we describe a case of a patient who had their TT break due to CPR. CASE PRESENTATION: A 69-year-old male presented as a level two trauma status post motor vehicle collision. His initial injury severity score was 29 with injuries including: left-sided rib fractures with flail segment of ribs 1-6, left hemopneumothorax, comminuted fracture of the left scapular body and spine, left clavicle fracture with emphysema and hematoma. The patient was admitted to the surgical intensive care unit with management including a thoracotomy for rib plating and evacuation of the hematoma. Preoperative imaging is shown in Figure 1. The patient underwent left posterolateral thoracotomy with open reduction and internal fixation of left ribs 3-7 with evacuation of subcutaneous hematoma and left hemothorax. A 28 French TT was placed in the left posterior apical position, and a curved 28 French TT was placed in the left posterior inferior position. A postoperative chest x-ray confirmed lung re-expansion (Figure 2). On post-operative day 1, the patient became hypoxic, hypotensive, and bradycardic leading to cardiac arrest. Advanced cardiac life support was initiated including CPR and epinephrine for eight minutes until return of spontaneous circulation was achieved. A chest x-ray post arrest was taken showing the rib plating was intact. On post-operative day 2, removal of the TT was attempted. The distal portion of the left TT broke and remained within the thoracic cavity. A computed tomography of the chest (Figure 3) showed the broken portion of the tube. On post-operative day 3, the patient underwent left mini thoracotomy, removal of the retained TT under ultrasound guidance, and replacement of the apical TT. The distal end of the curved chest tube was found to be entrapped within the anterior rib fractures that resulted from CPR and successfully removed. The rest of the patient’s admission was unremarkable and he was discharged to a rehabilitation facility. DISCUSSION: To our knowledge this is one of the first cases to describe entrapment of a TT as a result of CPR. Additionally, this is one of the few cases to describe the use of a thoracotomy for removal of an entrapped tube. Thoracotomy has been reported as a management strategy in a similar case in which a nasogastric tube became entrapped intratracheally following lobectomy. There remains a paucity of data on the true incidence of abnormal positioning of tubes and the role of thoracotomy in the management of these patients. CONCLUSIONS: We present the case of a broken entrapped TT and successful removal via thoracotomy. Reference #1: Hoke RS, Chamberlain D. (2004). Skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation, 63(3):327-38. Reference #2: Deliliga A, Chatzinikolaou F, Koutsoukis D, Chrysovergis I, Voultsos P. (2009). Cardiopulmonary resuscitation (CPR) complications encountered in forensic autopsy cases. BMC Emergency Medicine, 28;19(1):23. DISCLOSURES: No relevant relationships by Jordan Debbrecht, source=Web Response No relevant relationships by Katherine Foerster, source=Web Response no disclosure on file for Brian Gilbert; No relevant relationships by Michael Nguyen, source=Web Response no disclosure on file for George Philip; No relevant relationships by William Waswick, source=Web Response

Bleomycin pleurodesis in malignant pleural effusion

Objective: This is the first retrospective trial in our country to examine intrapleural bleomycin in terms of effectiveness, safety, and cost. The aim of this study was to investigate the effectiveness, safety and appropriate mode of administration of intrapleural bleomycin for pleurodesis, in the treatment of malignant pleural effusion.&#x0D; Methods: Between January and July2014, 30 patients presenting to Ibn-alnafees teaching hospital with symptomatic malignant pleural effusions were underwent chemical pleurodesis with bleomycin via bedside thoracostomy. Only the patients with lung re-expansion after drainage entered the study. The conditions of patients were assessed and graded before and after treatment concerning pain, dyspnea, and chest radiographs.&#x0D; Results: Thirty patients who underwent pleurodesis with bleomycin were available for follow-up. The patients demonstrated notable improvement in both pain and dyspnea following treatment. Permanent control of effusions, defined objectively on chest radiograph, was achieved with bleomycin treatments in 21(70%). The procedures were well tolerated and no significant adverse effects were observed.&#x0D; Conclusion: This study confirms that intrapleural bleomycin carries good results in the treatment of malignant pleural effusion. Pleurodesis using bleomycin with 72 hours applied suction should be offered to every patient with malignant pleural effusion, apart from terminally ill ones, provided that a satisfying lung re-expansion has been achieved. A careful selection is essential to define the proper technique.

Pleural Space Complications from Tuberculous Empyema: A Case Report and Short Literature Review

Tuberculous empyema (TE) is an uncommon form of pleural tuberculous (TB). Although the incidence of TE has significantly decreased, it still threatens public health. Patients with TE experience a protracted illness and significant morbidity and mortality risk. Male sex is a significant risk factor for TE. Herein, we report an adult case of TE admitted to a tertiary care hospital of Iran with clinical characteristics, treatment modalities, and outcomes of this disease. The duration of illness and duration of chest tube drainage equaled 7 months and 48 days, respectively. Our patient required surgery despite the administration of antituberculosis drugs and chest tube drainage. Due to the presence of parenchymal lesions, bronchopleural fistula, and failure of lung re-expansion after chest tube insertion, the patient required decortication with the closure of the bronchopleural fistula and additional thoracoplasty. In the case presentation, we emphasize difficulties encountered in the treatment of such patients.

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。

CUSTOMIZING AIRWAY STENT FOR MULTICENTRIC MALIGNANT AIRWAY OBSTRUCTION

TYPE: Abstract Publication TOPIC: Procedures PURPOSE: A middle-aged man with adenocarcinoma of sigmoid colon and solitary liver metastasis underwent neoadjuvant chemotherapy followed by hemicolectomy and hepatectomy. The cancer progressed and he developed endobronchial metastasis resulting in near-total obstruction of left main bronchus (LMB) and bilateral pulmonary nodules. METHODS: Laser photoresection of LMB tumor was performed followed by covered self-expanding metallic stent (SeMS). He received radiation and anti-angiogenic therapy. Six months later, he complained of worsening dyspnea and stridor. CT Thorax revealed complete occlusion of the distal end of stent with collapse of left lung. Rigid bronchoscopy revealed tumor in-growth through the stent; tumor at the main carina causing 70% obstruction of the right main bronchus (RMB), and a polypoidal mass arising from the right middle lobe bronchus. Tumor debulking was performed within the stent and at the carina with argon plasma coagulation (APC) and rigid forceps, and the polypoidal mass was removed with electrosurgical snare. The left limb of silicone Y stent was cut to accommodate the SeMS while another circular cut was made just beyond the take-off of the right limb. The right limb of Y stent was deployed into bronchus intermedius, the circular cut maintained aeration to the right upper lobe (RUL). Post procedural CXR showed re-expansion of the left lung with satisfactory position of the silicon and SeMS stents. RESULTS: Figure 1. Bronchoscopic images CONCLUSIONS: Complex Airway Obstruction interferes with airflow and insertion of airway stents provide relief and complement ablative techniques. Modification of stents may prove to be beneficial to these patients. CLINICAL IMPLICATIONS: Please refer above DISCLOSURE: No significant relationships. KEYWORDS: central airway obstruction, airway stent

Minimizing the Risk of Aerosol Contamination During Elective Lung Resection Surgery.

Background:In the setting of the COVID-19 pandemic, the conduct of elective cancer surgery has become an issue because of the need to balance the requirement to treat patients with the possibility of transmission of the virus by asymptomatic carriers. A particular concern is the potential for viral transmission by way of aerosol which may be generated during perioperative care. There are currently no guidelines for the conduct of elective lung resection surgery in this context.Methods:A working group composed of 1 thoracic surgeon, 2 anesthesiologists and 1 critical care specialist assessed the risk for aerosol during lung resection surgery and proposed steps for mitigation. After external review, a final draft was approved by the Committee for the Governance of Perioperative and Surgical Activities of the Hôpital Maisonneuve-Rosemont, in Montreal, Canada.Results:The working group divided the risk for aerosol into 6 time-points: (1) intubation and extubation; (2) Lung isolation and patient positioning; (3) access to the chest; (4) conduct of the surgical procedure; (5) procedure termination and lung re-expansion; (6) chest drainage. Mitigating strategies were proposed for each time-point.Conclusions:The situation with COVID-19 is an opportunity to re-evaluate operating room protocols both for the purposes of this pandemic and similar situations in the future. In the context of lung resection surgery, specific time points during the procedure seem to pose specific risks for the genesis of aerosol and thus should be the focus of attention.

Predictors of outcome of pleurodesis in patients with malignant pleural effusion: a systematic review and meta-analysis

ABSTRACT Objectives Pleurodesis is an important management option to palliate breathlessness in patients with malignant pleural effusion (MPE). This systematic review aimed to examine available literature for studies investigating factors that predict pleurodesis outcome. Methods The healthcare databases advanced search (HDAS) Medline and Embase in addition to Cochrane Database of Systematic Reviews were searched on for publications reporting on pleurodesis for MPE in English language. All study types reporting previously unpublished data on predictors of pleurodesis success were included. Thirty-four studies involving 4626 patients were included in the systematic review. Results The most common pleurodesis agent used was talc which was used in 27 studies. Meta-analyses demonstrated that the strongest predictors of pleurodesis success were higher pleural fluid pH, smaller volume of effusion pre-pleurodesis and full lung re-expansion post effusion drainage. Shorter duration of tube drainage, higher pleural fluid glucose, lower LDH, and lower pleural tumor burden all seem to favor pleurodesis success, but with considerable statistical heterogeneity between studies. Available data do not suggest that chest tube size affects pleurodesis outcome. Conclusion Overall, available results are difficult to interpret due to evidence quality. Prospective studies are needed to further explore these factors. Protocol registration CRD42018115874 (Prospero database of systematic reviews)