Double-lumen endobronchial tube (DLT) displacement often occurs in patients undergoing thoracic surgery after lateral positioning. There are no clinical studies investigating the effect of disconnection of the breathing circuit with DLT on the incidence of displacement after lateral positioning. Therefore, the aim of this study is to investigate the effect of disconnection of the breathing circuit with DLT on the rate of DLT displacement after lateral positioning in patients undergoing thoracic surgery. A single-blind, parallel-group, randomized controlled study will be conducted. We will recruit 256 patients who are scheduled to undergo elective thoracic surgery. The participants will be randomly allocated to the disconnected breathing circuit group and the connected breathing circuit group. The primary outcome is the rate of DLT displacement identified via the flexible bronchoscopy before and after lateral positioning. The secondary outcomes are the effect of lung collapse, peripheral oxygen saturation at 5 and 10 min after one-lung ventilation, and the length of stay in the post-anesthesia care unit (PACU). Several studies have shown promising results in reducing the incidence of DLT displacement during lateral positioning. However, no studies have investigated the effect of the disconnection of the breathing circuit from the DLT on the rate of DLT displacement after lateral positioning. We expect that disconnecting the breathing circuit when changing the patient from supine to lateral position will avoid unintended tube traction, thus reducing the incidence of DLT displacement. The study protocol was registered at Clinical Trials (https://register. gov/) with registration number: NCT06182371 on November 21, 2023.

Not All Black and White: Is Routine Chest Radiography Following Rib Fractures Beneficial?

Introduction: Spontaneous pneumothorax occurs when part of the lung collapses and air accumulates in the pleural space. The cause of spontaneous pneumothorax is unclear, but this condition may increase the risk of death, particularly if it progresses to tension pneumothorax.COVID-19 is primarily a respiratory disease and may present with various pulmonary manifestations, including rare and severe complications. Case: A 48-year-old woman presented with dyspnea, fever, cough, nausea, and fatigue. Initial rapid antibody testing for SARS-CoV-2 wasnegative. Chest radiograph demonstrated an avascular area in the right lateral hemithorax with medial lung collapse, consistent with right spontaneous pneumothorax. Oxygen therapy and chest tube insertion were performed. Follow up chest x-ray showed resolution of the rightpneumothorax, however, a new pneumothorax developed on the left side. Nasopharyngeal and oropharyngeal swab testing for SARS-CoV-2 was reported positive a few days later, after the patient had died. Discussion: The occurrence of bilateral spontaneous pneumothoraxin this patient suggests lung involvement related to COVID-19 infection. Recognition of atypical pulmonary manifestations is essential, particularly when initial screening tests are negative. Conclusion: COVID-19 can manifest as spontaneous pneumothorax, including bilateral involvement. Early recognition is important to reduce morbidity and mortality.

Background: Bronchoscopy was introduced in the late nineteenth century and its use is tremendously increased for several diagnostic and therapeutic purposes. However, it role for acute respiratory failure in our institution is still lacking. The aim of this study was to make an updated revision on the clinical conditions for bronchoscopy in adults with acute respiratory failure and to assess the high risky patients during the bronchoscopy procedure Patients and Methods: This was a cross-sectional study. It included 90 patients with acute respiratory failure with hypoxemia. According to initial (provisional) diagnosis, there were 6 groups (each 15 patient): 1) Pneumonic hypoxemic group, 2) ILD hypoxemic group, 3) Neoplastic hypoxemic group, 4) Hemoptysis hypoxemic group, 5) Perioperative hypoxemic group, and 6) Foreign body aspiration hypoxemic group. All were evaluated by full history taking, clinical examination, and laboratory investigations. Furthermore, bronchoscopy was performed for all patients and results were documented Results: The findings from this study demonstrated that bronchoscopy was particularly effective in resolving airway obstruction, clearing mucus plugs, managing hemoptysis, and obtaining diagnostic samples for cytological and histopathological evaluation. The procedure produced diagnostic yield and improved patient outcomes, especially in cases of pneumonia, neoplastic obstruction, and postoperative lung collapse. Bronchoscopy is generally a safe procedure when performed with proper monitoring and patient selection, even in critically ill individuals. Conclusion: Bronchoscopy plays a pivotal role in the diagnosis and management of patients with acute respiratory failure. Its use provides direct visualization of the airways, enabling accurate identification of underlying causes such as infection, malignancy, airway obstruction, and foreign body aspiration. The findings from this study demonstrated that bronchoscopy significantly contributed to both diagnostic clarification and therapeutic intervention across a variety of clinical conditions.

Reevaluating routine chest X-rays after chest tube removal in traumatic pneumothorax

Commercial air travel exposes passengers to reduced cabin pressures, causing intrathoracic gas volume to expand (Boyle's law). Guidelines recommend waiting 7-14 days after radiographic resolution of a pneumothorax before flying; however, such recommendations may not reflect emerging evidence for select cases. We report a case of a healthy 51-year-old man with a small (< 10%) traumatic pneumothorax who flew domestically and internationally within 4 and 9 days of diagnosis against medical advice. He remained asymptomatic, with serial chest X-rays indicating stability and eventual resolution of the pneumothorax. The patient demonstrated clinical and radiographic stability despite commercial cabin pressure changes and high-altitude activity. The presented case supports and extends a growing body of research, suggesting that patients with normal oxygen saturation on room air may safely tolerate air travel with a small, stable, traumatic pneumothorax. This case highlights the potential need for individualised risk assessment when advising travel delays.

During pulmonary surgery, the lung is deflated to facilitate the procedure. This study aimed to assess the deformation of the bronchial tree and pulmonary parenchyma during lung collapse, for eventual use in augmented reality (AR) guidance during pulmonary resections. The concept was first tested in 2 porcine models by analyzing paired computed tomography scans of collapsed and inflated lungs, then applied to 6 human patients. Bronchus and parenchyma were segmented, and a bronchus centerline was calculated. The diameter, length differences, angular deformations, and volume differences of the parenchyma were calculated. Finally, these deformations were applied on the inflated bronchus centerline to generate an artificially collapsed bronchus. In both the porcine and human models, the pulmonary collapse resulted in substantial volumetric and anatomical changes. For the humans, the right lung showed a median displacement of 14.41 mm in the dorsomedial direction, while the left lung was displaced 11.99 mm in the dorsolateral direction (P = 0.79). Median volume reduction was 970 mL for the right lung and 878 mL for the left lung. Bronchial narrowing was observed, with a median diameter reduction of 0.14 mm for the right lung and 1.23 mm for the left lung. Moreover, the lengths of the bronchial segments were reduced, with a median length reduction of 0.20 mm for the right sided and 0.72 mm for the left sided. Algorithmically driven calculations of the intraoperative pulmonary collapse of human and porcine lungs were performed and applied onto an inspirated bronchus. This resulted in an artificial collapsed bronchus. This method could be a foundation for a dynamical deformable deflation model, suitable for intraoperative AR-based pulmonary navigation.

As an effective alternative therapy, acupuncture is increasingly recognized and utilized worldwide. While acupuncture is used to treat neurological, respiratory, and circulatory disorders, its clinical efficacy is influenced by various factors. Even minimal stabbing wounds may cause physical injury or be life-threatening if done improperly. We report the case of a young man who died suddenly after receiving acupuncture treatment. Autopsy revealed multiple needlestick wounds in the bilateral lungs, liver, and spleen, leading to traumatic pneumothorax and hemoperitoneum, and the man ultimately died of respiratory failure. Notably, the case documentation mentioned only dorsal acupuncture. However, during the autopsy, we discovered additional puncture sites in the bilateral lateral regions, with dimensional discrepancies compared to the dorsal needlestick. We hypothesized that these discrepancies were caused by the use of needles of varying sizes and raised reasonable suspicion of multiple perpetrators. A subsequent law enforcement investigation confirmed that the man's dorsal and lateral acupuncture were performed separately by a masseur at a private clinic and by his partner. A detailed analysis clarified how injuries to different anatomical regions contributed to the fatal outcome, providing a foundation for legal accountability. The uniqueness of this case lies in the involvement of multiple suspects, multiple organ injuries, and unlicensed medical practice. This case not only enriches the report on adverse events associated with acupuncture but also highlights the critical importance of meticulous forensic examination and comprehensive case investigation.

We report the case of a 60-year-old female with adenocarcinoma of the right upper lobe who underwent a video-assisted thoracoscopic surgery (VATS) upper lobectomy and subsequently presented with complete right lung collapse in the immediate postoperative period. Urgent bronchoscopy revealed complete stapling of the right mainstem bronchus. Hence, emergency re-exploration and bronchoplasty of the right mainstem bronchus and the right lower-lobe bronchus were done. While bronchoscopy following VATS lobectomy for lung cancer poses technical challenges and represents an independent risk factor for postoperative pulmonary complications, it remains a valuable tool for the early detection of complications such as lung collapse, which may result from thick mucus, a foreign body, iatrogenic injury, or the tumour itself.

BackgroundTraumatic pneumothorax is a potentially life-threatening condition requiring timely diagnosis and management, particularly in the prehospital setting where diagnostic tools are limited. This study aimed to evaluate the diagnostic performance of clinical signs used by emergency physicians in the field to identify traumatic pneumothorax requiring early thoracic decompression.MethodsWe conducted a retrospective observational study in a French level I trauma center from January 2015 to August 2022. All patients with CT-confirmed pneumothorax managed by prehospital emergency physicians were included. The primary endpoint was the diagnostic performance of prehospital clinical assessment to identify pneumothorax requiring early decompression (prehospital or within four hours of admission). Statistical analysis was focused on predictive performance of three clinical signs (asymmetric lung auscultation, thoracic expansion asymmetry, and subcutaneous emphysema) in identifying cases requiring early decompression, using univariable analyses and the construction of a composite predictive score by logistic regression.ResultsAmong 280 included patients, 115 (41%) required early thoracic decompression. Clinical suspicion of pneumothorax was present in 63% (95% CI: 54‒71) of these cases. Asymmetric lung auscultation showed the highest sensitivity (74%; 95% CI: 62‒86), while subcutaneous emphysema demonstrated the highest specificity (79%; 95% CI: 68‒89). The overall clinical suspicion rate across the cohort was 46% (95% CI: 41‒52). A composite predictive score using the three clinical signs demonstrated better diagnostic performance (AUC 0.63 (95% CI 0.57‒0.69); score = 1 OR 2.0 [95% CI 1.1‒3.6], score = 2 OR 3.0 [95% CI 1.6‒5.7]; score = 3 OR 11.0 [95% CI 1.3‒96.8]).ConclusionPrehospital clinical assessment alone had limited diagnostic performance for detecting blunt traumatic pneumothorax requiring early decompression. A simple clinical composite score offers higher specificity but remains insufficiently sensitive to be used as a standalone diagnostic tool; it may support field decision-making as a risk-stratification aid, but prehospital clinical signs alone are not sufficient to rule out a pneumothorax requiring early decompression.

BackgroundCurrent understanding indicates that primary spontaneous pneumothorax (PSP) typically occurs in younger individuals, whereas secondary spontaneous pneumothorax (SSP) is more common in older patients. However, the specific age distribution patterns distinguishing these two types of spontaneous pneumothorax (SP) remain poorly characterized. Furthermore, while a low partial pressure of oxygen (PaO₂) is a recognized clinical feature of pneumothorax, limited research has explored whether lower PaO₂ levels are specifically indicative of underlying lung disease in patients with SSP.MethodsIn this observational cohort study, we enrolled 473 male SP patients over a six-year period. We use frequency distribution plots to observe the distribution differences of continuous variables between SSP and PSP patients. Receiver operating characteristic (ROC) curve analysis and logistic regression modeling were employed to quantify the association between age, PaO₂, and SSP.ResultsThe frequency distributions of age and PaO₂ were bimodal in patients with PSP and SSP. Multivariate logistic regression analysis identified age (using a cutoff of > 50 vs. ≤50 years) and PaO₂ (using a cutoff of > 90 vs. ≤90 mmHg) as independent factors associated with SSP, with odds ratios (ORs) of 10.58 (95% CI: 6.15–18.20) and 0.45 (95% CI: 0.27–0.74), respectively. While alternative cutoffs of age (> 40 vs. ≤40 years) and PaO₂ (> 85 vs. ≤85 mmHg) were also significant, with ORs of 7.74 (95% CI: 4.46–13.41) and 0.32 (95% CI: 0.19–0.55), the OR for age was lower (a decrease of 2.84 from the > 50-year cutoff). ROC curve analysis showed that the sensitivity and specificity for distinguishing SSP were 0.835 (95%CI: 0.812–0.853) and 0.789 (95%CI: 0.779–0.801), respectively, for the 50-year age cutoff, and 0.746 (95% CI: 0.721–0.762) and 0.679 (95%CI: 0.652–0.698) for the 90 mmHg PaO₂ cutoff.ConclusionAmong male patients with SP, an age of 50 years offers higher sensitivity and specificity than an age of 40 years in distinguishing SSP from PSP. Furthermore, even after oxygen administration, PaO₂ levels in SSP patients remain lower than those in PSP patients. A PaO₂ threshold of 90 mmHg also demonstrates high sensitivity and specificity in differentiating SSP from PSP.

ABSTRACTIntrathoracic lipomas are rare benign tumours that may attain considerable size before detection. We report a 38‐year‐old woman in whom a huge intrathoracic lipoma was incidentally identified on chest radiography during preoperative assessment. Computed tomography demonstrated a large, well‐circumscribed fat‐attenuation lesion occupying nearly the entire right hemithorax, causing near‐total lung collapse and mediastinal shift. Image‐guided biopsy confirmed a benign lipoma. This case highlights the characteristic imaging features of intrathoracic lipoma and underscores the importance of histopathological confirmation to exclude liposarcoma, even in asymptomatic patients with marked thoracic compression.

Lung collapse during postural repositioning in a mechanically ventilated patient, could it have been avoided? A case report

Postoperative sore throat and hoarseness are common complications following lung isolation with double-lumen tubes (DLTs) in video-assisted thoracoscopic surgery (VATS). Laryngeal mask airway (LMA) combined with a visual bronchial blocker (VBB) may reduce airway trauma while maintaining effective lung isolation. This is a prospective, randomised, controlled, single-blind, multicentre clinical trial conducted at three major thoracic surgery centres in Shanghai, China. A total of 270 patients aged ≥18 years scheduled for elective VATS anatomical lung resection will be randomly allocated 1:1 to either the VBB group (n=135) using LMA combined with VBB or the DLT group (n=135) using conventional DLT (see Consolidated Standards of Reporting Trials diagram). The primary outcome is the incidence of sore throat and hoarseness at 24 hours postoperatively. Secondary outcomes include sore throat and hoarseness at 1 and 48 hours, intraoperative device performance, lung collapse quality, intubation time, haemodynamic changes, emergence quality, device-related complications and hospital length of stay. The study protocol was approved by the Ethics Committee of Shanghai Chest Hospital (KS24042). Results will be disseminated through peer-reviewed publications and conference presentations. ClinicalTrials.gov (NCT07117539).

Atelectasis, characterized by partial or complete lung collapse, presents notable challenges in both diagnosis and treatment. Timely identification is essential to avoid further pulmonary complications and to facilitate early intervention. Leveraging artificial intelligence for the automated detection of atelectasis can significantly improve diagnostic efficiency, reduce clinical workload, and enhance patient care. This work presents an interpretable deep learning model that synergistically integrates Xception, Transformer, and Capsule Network components for the accurate detection of atelectasis from chest radiographs. The Xception module is employed to extract spatially rich features, while the Transformer component models long-range dependencies critical for understanding complex anatomical patterns. The Capsule Network further enhances the system’s sensitivity to subtle structural variations associated with atelectatic regions. The training and validation of the model were conducted using a publicly accessible chest X-ray dataset, achieving impressive performance metrics: 99.73% accuracy, 99.74% sensitivity, and an F1 score of 99.73%. Furthermore, to evaluate the model’s generalizability, external validation was performed using the NIH ChestX-ray dataset, which demonstrated consistent performance and highlighted the applicability of the proposed approach beyond the primary dataset. These results underscore the model’s capability for reliable and interpretable automated diagnosis, supporting its future integration into clinical workflows.

Background: Pneumothorax (PTX) develops in 1–2% of neonates, leading to significant morbidity and mortality and requiring providers to be comfortable with management. Our objective was to evaluate whether radiographic measurements of PTX size can be used to predict the need for procedural intervention in neonates in order to help guide the need for the availability of specific personnel. Methods: With the help of a data analyst, 62 patients diagnosed with neonatal PTX between March 2016 and October 2024 were identified. Most babies (46) were born in 2023–2024 when our new electronic health record could more easily identify these infants. PTX size was evaluated using radiographs by calculating the ratio of the widest transverse measurement of the PTX on both anteroposterior (AP) and, when available, lateral decubitus (DECUB) divided by the widest transverse measurement of the hemithorax above the diaphragm. Clinical data were collected, and statistical analysis was performed using need for intervention (thoracentesis (TC), chest tube (CT), or both). Results: We found that a larger PTX size ratio, measured in the AP (p < 0.0001) or DECUB view (p < 0.008), was highly associated with need for intervention in this cohort of infants with PTX. Only 33% of PTXs required intervention. Also, 13/14 (93%) cases who underwent TC ultimately required a CT. PTX was more prevalent in males in general, but sex was not associated with needing intervention. The average gestational age (GA) of the cohort was 36 5/7 weeks, with only 12% being < 34 weeks GA. Univariate analysis indicated that lower GA and birth weight were risk factors for intervention. There was a trend (p = 0.075, by Fisher’s exact test) suggesting that infants with both respiratory distress syndrome (RDS) and PTX may be more likely (60%) to require intervention (no RDS, 29% intervention). Finally, a receiver operator characteristic curve was derived from the AP ratio based on the yes/no intervention which resulted in an area under the curve statistic of 0.902 and the optimal AP ratio cutoff of 0.184. Conclusions: The ratio of the transverse measurement of the PTX/hemithorax size from radiographs was highly predictive for need for intervention in a cohort of primarily term infants with PTX. Smaller and lower GA infants were at a higher risk for requiring procedural intervention. Nearly all infants who had TC also needed a CT. These findings could inform clinical strategies for managing neonatal PTXs, especially in identifying appropriate needed personnel availability if a TC occurs.

Background and objectivesMinimally invasive coronary artery bypass grafting (MIDCAB) requires effective left lung isolation, yet evidence comparing video-imaging single-lumen tracheal tubes with bronchial blockers (VSLT + BB) and video-imaging double-lumen endotracheal tubes (VDLT) remains limited. This randomized controlled trial aimed to: (1) quantitatively compare time efficiency for device placement and lung isolation between VSLT + BB and VDLT; (2) evaluate perioperative airway complications; and (3) assess differential impacts on postoperative recovery, including postoperative sore throat, hoarseness, and Quality of Recovery-15 (QoR-15) scores.MethodsIn this single-blind randomized controlled trial, 97 MIDCAB patients were allocated to VSLT + BB or VDLT groups. Primary outcomes were tube positioning time; secondary outcomes included total intubation time, oxygenation parameters, hemodynamic variables, and postoperative complications.ResultsVDLT exhibited shorter tube positioning time (128 ± 37 vs. 159 ± 58 s; p < 0.001) but longer total intubation time (192 ± 40 vs. 159 ± 58 s; p < 0.001). VSLT + BB demonstrated higher PaO₂ at 10-min post-OLV (226.0 vs. 168.0 mmHg; p = 0.035) with lower airway pressures (p < 0.05). Postoperative sore throat (33% vs. 13%; OR 2.84, 95% CI 1.04, 7.71; p = 0.018) and hoarseness at 48 h (55% vs. 31%; OR 2.45, 95% CI 1.08, 5.59; p = 0.018) were higher with VDLT. Lung collapse quality, hypoxemia rates, pulmonary complications, and QoR-15 scores showed no significant differences (all p > 0.05).ConclusionsIn MIDCAB surgery, VDLT demonstrated significantly shorter tube positioning time compared with VSLT + BB. However, VSLT + BB exhibited shorter total intubation time than VDLT by avoiding postoperative tube exchange. Both techniques provided clinically acceptable lung isolation with comparable lung collapse quality and hypoxemia incidence. VSLT + BB exhibited lower airway pressures and higher oxygenation indices during early OLV, whereas VDLT was associated with higher rates of minor airway complications (sore throat, hoarseness). No significant differences were observed in pulmonary complications, hemodynamic stability, or recovery quality.Trial registrationChiCTR2300072124, 3/6/2023.

Rosai-Dorfman disease (RDD) is a rare, benign non-Langerhans cell histiocytosis characterized by the accumulation of CD68⁺, S100⁺, and CD1a⁻ histiocytes, typically presenting as massive, painless cervical lymphadenopathy. Pulmonary involvement in RDD is exceedingly rare. It may manifest with respiratory symptoms, such as chronic cough, dyspnea, and chest pain. We describe the case of a 23-year-old male with immune-related RDD and coexistent juvenile idiopathic arthritis (JIA), who presented with fever, chronic cough, and progressive dyspnea. Imaging revealed extensive bilateral pulmonary involvement and lymph node histopathology confirmed RDD. During hospitalization, the patient developed a right-sided secondary spontaneous pneumothorax, a complication not previously reported in pulmonary RDD. This case highlights the unusual co-occurrence of RDD and JIA with extensive pulmonary involvement culminating in spontaneous pneumothorax. It underscores the importance of considering RDD in the differential diagnosis of atypical pulmonary presentations in young patients, particularly those with underlying autoimmune rheumatic diseases.

Prospective Comparison of Short vs Long Chest Tube Water Seal Trial for Traumatic Pneumothorax.

Background: Traumatic pneumothorax is the second most common chest injury, with approximately 50,000 cases annually in the US. It is a life-threatening condition that can rapidly progress to tension physiology, leading to obstructive shock and cardiac arrest. Effective prehospital management by Emergency Medical Services (EMS) is critical for patient survival, as timely intervention can prevent respiratory and hemodynamic collapse. Aim: This review aims to synthesize current evidence and guidelines for the prehospital recognition and management of traumatic pneumothorax, focusing on clinical assessment, rapid intervention strategies, and the advancement of EMS practice through technology and protocol optimization. Methods: A comprehensive literature review was conducted, analyzing established trauma protocols, clinical studies on intervention efficacy, and data on evolving prehospital technologies such as point-of-care ultrasound (POCUS). The pathophysiological basis for different pneumothorax types (simple, tension, open) and corresponding management techniques were evaluated. Results: Prehospital recognition relies on a high index of suspicion based on mechanism of injury and signs like hypoxia, unilateral absent breath sounds, and hypotension. Needle thoracostomy remains the lifesaving intervention for suspected tension pneumothorax, with a growing preference for the 4th/5th intercostal space mid-axillary approach over the traditional 2nd intercostal mid-clavicular site due to higher success rates. For open ("sucking") chest wounds, application of an occlusive dressing—now often a commercially available, fully sealed device—is standard. The integration of portable POCUS shows promise for earlier field diagnosis but requires further outcome validation. Conclusion: Optimal prehospital outcomes depend on systematic assessment, protocol-driven decision-making, and proficiency in critical interventions. While techniques and equipment evolve, the cornerstone of care is the EMS provider's ability to recognize life-threatening physiology and act decisively. Ongoing training, research, and interdisciplinary collaboration are essential to standardize and advance prehospital trauma care.